NATIONAL . CENTER NCI For HEALTH Number § haan mea plan and operation of a Health Examination Survey of U.S. Youths 12-17 Years of Age U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Public Health Service Publication No. 1000-Series 1-No. 8 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C., 20402 - Price 75 cents NATIONAL CENTER| Series 1 For HEALTH STATISTICS | Number 8 VITALand HEALTH STATISTICS PROGRAMS AND COLLECTION PROCEDURES plan and operation of a Health Examination Survey of U.S. Youths 12-117 Years of Age A description of the Health Examination Survey's third cycle—examinations of a probability sample of United States youths 12-17 years of age. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Washington, D.C. 13 September 1969 NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, PH.D., Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development ALICE M. WATERHOUSE, M.D., Medical Consultant JAMES E. KELLY, D.D.S., Dental Advisor EDWARD E. MINTY, Executive Officer MARGERY R. CUNNINGHAM, Information Officer DIVISION OF HEALTH EXAMINATION STATISTICS ARTHUR J. McDOWELL, Director PAUL T. BRUYERE, M.D., Deputy Director JAMES T. BAIRD, JR., Chief, Analysis and Reports Branch HENRY W. MILLER, Chief, Operations and Quality Control Branch PETER V. V. HAMILL, M.D., Medical Advisor JAMES E. KELLY, D.D.S., Dental Advisor HAROLD J]. DUPUY, Ph.D., Psychological Advisor Public Health Service Publication No. 1000-Series 1-No. 8 Library of Congress Catalog Card Number 76-602407 PREFACE This report presents a detailed description ofthe ''third cycle" plan and operation of the Health Examination Survey. Itis intended primarily to serve as a necessary foundation for understanding and use of the sub- stantive findings to be published later in the Vital and Health Statistics, Series 11 reports of the National Center for Health Statistics. It is hoped that it will also serve as a useful guide or aid to others in the planning of health examination surveys. In the planning and operation of the ''third cycle," valuable assist- ance was received from many individuals and groups. Space does not permit the recognition of all who participated in the planning, develop- ment, and conduct of the many and varied aspects of the survey. Their assistance is, however, gratefully acknowledged. Mention should be made, however, of the important role played by the U.S. Bureau of the Census. Under a contractual arrangement they have participated in certain as- pects of the sample selection, conduct of initial household interviews, and in most of the processing of the data. The overall responsibility for planning the program was that of Mr. Arthur J. McDowell, Director, Division of Health Examination Statistics. The primary responsibility for the content and coordination of the various parts of the examination was that of Dr. Peter V,V. Hamill, Medical Advisor for the children and youth programs of the Division of Health Examination Statistics (DHES). Other members of the DHES staff who had responsibility in specific areas were Dr, James E. Kelly, Dental Advisor to the National Center for Health Statistics; Dr. Lawrence E. Van Kirk, Jr., formerly Dental Advisor to DHES; Miss Jean Roberts, Supervisory Statistician (DHES); and Dr. Lois R. Chatham, formerly Psychological Advisor to DHES. This report was prepared by Henry W. Miller. CONTENTS TE COC TITY, om sm osm wt Fs, 0 eo Te ig 0 HES General PIrOSraIm meee «ooo mm no oo mo sm mm mm Basic CharacteristiCS=----mre-meme cece cece meee meme mm mm mm Programs toDate--==mmme-cmcm emcee eee eee mmm mee DeVElOPINENL OF CYTE TTT ww mr arm ce or ms 0 ee em mm ee em The Target Population=--=--===m memo eee eee meee em Determination of General Objectives-=--=mmmemememeee cee mm Development of Specific AT@aS-~ =m mmm remem sm se mn Pilot Testinge-mmeremnrmeecn enema e mer ——— ee ————————————————— The Sample Design ~--=-eeceememmcmccee cece eee e emcee mm ———— SITNIATILY 10 CYTE T= moro mit mm mimo mm wim tm 5m, 0m rs mm sr mm Subsampling =-==-=eemcec meme ccc e mmm ———— me ————— Other Sampling ASPECES = == m= mmo om mmo mm mo om mim mm i rm mm mm me mm Sampling Features of the Examination-----=-======emme meee eee mam Stand Sequencing and Scheduling--=-=-==r=r=cemmemcece——————————— Advance Arrangements ~----eme-cememccmmc meee —— em ———————————— Professional RelationS--=-e--ccmcemeemcmec ecco mm ee Public RelationS--=--ecmccemcc meee ——_—— LOGISTICAL ATT ANGOITICNIS ~~ = =m om mow mm mem mm mi eo Household Interviewing ProcedureS-----m=m-mememmomeeccee————————————— Census INervIeWing =m -mm=e oe ————— mf em me om em mm HES INCrVIEWING mo mmm mm mor mo cm mm om mr tm rm em Appointment and Transportation Procedures----=====-emmemmemmenmem-—=- Examination Center and FLETA STapfl eo ww umes ms m monn wm ion omnes an on ios os ee ms os oon we on EXOMNINGTION: PY OT EOIUTL CIE wwe wmisniw mtr or 8 to 0 58000 0 050 ne sm es os 5 KTOTYOT AT ovine sive sesso ses ooo 3 we ow BE DW 0 IE SY TT TED te eto sos ln sleet ei sd RA loo The Examination by Physician and Nurse----=-==-mccommmommmmccaaeeme DOTIEO] TE SV TH LIVE CR ree isu mi i si oo oo NLS ON) | ATTY YVTE El OV 500s esos mr rs se: oe se et ea Psychological Testing---==--=---=cmmcemmmo cece meee eee meme Procedures Performed by Technicians=-===-=m-mmmmmmmmmmmmomaae aaa SUPDICTNIOIEAT DIRTR = mime mmm mim i i mo fs te ms i 08 Reasons for Collection-=-==~====mmmemmmm me mmm mmm ———————————— em me Description of Supplemental Documents--=--===-==m=cm-cmmemecmccmenn—- MN i hi — = ww aR WWW N= pm ~ OO == Bob WO Ww — ar U1 in a co oO NNN NN Ub hh WOO oo NNN cd CONTENTS—Con. Quality Control=m=m mmm me meee ee eee ecm mem References Appendix Appendix Appendix Appendix Appendix Appendix IA. i —— — ——— ——— - — ——————— ————————— HES Household Questionnaire--=--=-=-m-cooommmmmomceaono- Medical History of Youth====cac como mcmmeeeeeeeoo . Health Habits and HiStOry=======-mc comme eee Supplemental Information From School----===-cemmmeemoaoan- Health Behavior -=--==mecmmmm cme meee oe . HES Examination FOrmse=emmmmmam moc eee eee 35 39 49 35 58 62 vi THIS REPORT IS a detailed description of the thivd program of the Health Examination Survey, The actual collection of data for this pro- gram began in Mavch 1966 and will be completed early in calendar year 1970, It involves the selection and examination of a nationwide proba- bility sample of the civilian, noninstitutionalized population of the United States between the ages of 12 and 17 years, The examination focuses primarily on factors velating to growth and development. It includes examination by a physician, a dental examination, a variety of tests, procedures, measurements, and a battery of psychological tests, This report describes the development of the survey plan, the examination content, the logistics of operations, and procedures employed to assure the quality of the data, During the course of the survey, 40 locations throughout the United States will be visited, Approximately 7,500 youths will be in the sample; of this number 90,0 percent are expected to be examined, A unique feature of the present program is the sample design whichutilizes the same sam- ple areas and housing units as the previous survey progvam, That pro- gram conducted during 1963-65, examined 7,119 children between the ages of 6 and 11 years, As a result of this feature, examination data of a longitudinal nature will also be available for approximately 2,200 youths, PLAN AND OPERATION OF A HEALTH EXAMINATION SURVEY OF US. YOUTHS 12-17 YEARS OF AGE INTRODUCTION The Health Examination Survey is one of the major programs of the National Center for Health Statistics (NCHS). Itis a part of the National Health Survey, authorized in 1956 by the 84th Congress as a continuing Public Health Service activity, The National Health Survey employs three different programs to accomplish its objectives,’ One of these is the Health Interview Survey which collects information about health and disability of the civilian, noninstitutionalized population through a continuous sampling and interviewing program. The second program, Health Resources, obtains health data and health resource and utili- zation information through surveys of hospitals, nursing homes, clinics, physicians' offices, lab- oratories, related facilities, and the entire range of personnel in the health occupations. The third major program of the National Health Survey is the Health Examination Survey (HES). The Health Examination Survey collects data by drawing samples of the civilian, noninstitu- tionalized population of the United States and, by means of medical and dental examinations and var- ious tests and measurements, undertakes tochar- acterize the population under study. This is the most accurate way to obtain definite diagnostic data on the prevalence of certainmedically defined illnesses. It is the only way to obtain information on unrecognized and undiagnosed conditions—in some cases, even nonsymptomatic conditions. It is also the only way to obtain distributions of the population by a variety of physical, physiological, and psychological measurements, In addition to the data collected by the ex- amining, measuring, and testing procedures, a wide range of other data is collected concerning each of the sample persons examined. Therefore, it is not only possible to study the many potential ‘felationships of the examination findings to one another, but also to investigate the relationships of the examination findings to demographic and socioeconomic factors. HES GENERAL PROGRAM Basic Characteristics The overall plan of the Health Examination Survey is to conduct successive, separate pro- grams of medical and dental examinations, tests, and measurements in specific age segments of the civilian, noninstitutionalized U.S, population, These successive programs are referred to as "cycles" and as such, eachhas a specific age seg- ment for the target population and is concerned with certain specified health aspects of that sub- population, All HES cycles make use of a nationwide prob- ability sample of the population, This makes it possible to obtain the desired information effi- ciently and in such a manner that the statistical reliability of results is determinable. These factors, together with the fact that the examina- tion and measurement processes are highly standardized and closely controlled, enable the results of the surveys to describe the entire pop- ulation of the United States on the basis of rela- tively small samples. The approach to each cycle is necessarily multidisciplinary in nature. Each draws on and combines the talents of statisticans, physicians of various specialties, dentists, psychologists, nurses, educators, sociologists, management spe- cialists, and others. In addition, each cycle in- volves interagency collaboration. The Bureau of the Census is a partner in several phases of the survey. Other Federal agencies such as the Na- tional Institutes of Health, the Office of Education, and the Children's Bureau, as well as nongovern- ment agencies such as schools of public health, medical research centers, and survey research agencies, also advise and assist the survey. The data collected are a cross section of a national sample of the civilian, noninstitution- alized population. The size of the sample permits some analysis of the data by broad geographic region, population density groups, or other major subgroups of the total sample, but it does not per- mit analysis by smaller breakdowns, such as by State. The data are analyzed and the findings are made available to interested persons as rapidly as possible. This is done primarily through the publication of reports prepared in a form usable by large numbers of consumers of health statis- tics. The reports are limited to objective, sci- entific presentation of the particular findings, including estimated levels of prevalence and rele- vant discussion of various observed relationships. They do not include discussion of program impli- cations of these findings, nor do they present value judgments concerning their implications to public health. The principal reports are published in the various Vital and Health Statistics series of the National Center for Health Statistics. Any information which permits the identifi- cation of an examinee is held in strict confidence, is not disclosed or released to others, and is used only by persons engaged in the survey for the purposes of the survey, Programs to Date The first program, or ''cycle," of the Health Examination Survey was conducted between No- vember 1959 and December 1962 and was directed toward the civilian, noninstitutionalized U.S. pop- ulation between the ages of 18 and 79 years inclu- sive. The examination was focused primarily on certain chronic diseases, cardiovascular disease, arthritis and rheumatism, and diabetes. Also in- cluded were a dental examination, tests for visual and auditory acuity, X-ray, electrocardiographic tracings, blood chemistry tests, and numerous body measurements. The sample size of that cycle was 7,710 persons of which 6,672 (86.5 percent) were examined. Details of the plan of that pro- gram are described in an earlier report.? Re- ports of various methodological studies 3-11 and of the findings 1243 are also available. The target population of the second cycle of the Health Examination Survey consisted of chil- dren between the ages of 6and 11 years inclusive, That cycle became operational in July 1963 and was concluded in December 1965. The primary focus of the examination was on various param- eters of growth and development, but it also screened for heart disease, congenital abnormal- ities, ENT diseases, and neuromusculoskeletal abnormalities. The size of the sample was 7,417 of which 7,119 (96.0 percent) were examined. A detailed report of the plan, operation, and response results, as well as several methodological re- ports, have been published.*+*8% Reports of find- ings are becoming available and will increase rapidly now that the analysis of the first cycle data is virtually completed. The third cycle, which is described in this report, is concerned with youths 12-17 years of age inclusive. This survey was begun in March 1966 and will be concluded early in calendar year 1970. The operation of the Health Examination Sur- vey at this time, therefore, is actually proceeding on three different levels. First, data are being collected in Cycle III. Second, analysis and pub- lication of data from Cyclell is being performed. Third, plans and preparations for Cycle IV are being made so that when Cycle III data collection is completed, Cycle IV examinations can be started, There are a number of reasons for this three-level concept of operation, but the principal one is to avoid complete dismantling and rebuild- ing of the field organization between examining phases of successive cycles. It also avoids the loss of highly trained field and headquarters per- sonnel whose skills are unique and difficult to replace. DEVELOPMENT OF CYCLE Iii The Target Population The age segment to be examined in Cycle III had been fairly well defined at the timethe target population of Cycle II was determined. Theorigi- nal concept of the second cycle was that the sample would consist of persons between the ages of 6 and 17 years inclusive. As the detailed planning pro- ceeded, it became apparent that the differences in the health, mental, and behavioral characteris- tics of the youths within this age range were great enough to warrant separate programs. Such mat- ters as feasibility of self-administered tests, motivational approaches to be used, sizes ofcer- tain supplies and equipment, and adverse effect on participation on the part of teenagers in a program that seemed to be a "children's" exami- nation led to a decision to limit the age range. It was then decided that the target population for Cycle II would be children between the ages of 6 and 11 years inclusive and the subsequent Cycle III program would include youths between the ages of 12 and 17 years. Aside from age, the other specifications of the Cycle III target population are quite similar to those in Cycle II. Specifications for Cycle III include the following: 1. Be between the ages of 12 and 17 years inclusive, regardless of whether they were attending school. 2. Married youths of eligible age are to be included. 3. Not confined to an institution. 4. Be a resident of the United States (includ- ing Alaska and Hawaii). 5. Not residing upon any of the reservation lands set aside for use of American In- dians. Determination of General Objectives It was clear early in the planning stages that the general objectives of the third cycle should be similar to those of Cycle II. Measures of growth and development as well as statistics on other health characteristics needed to be made avail- able for the entire continuum of childhood through adolescence. However, for reasons mentioned previously and from the experience of the previ- ous cycle, some modifications and refinements of the Cycle II collection techniques and proce- dures were indicated. In addition, data related specifically to adolescent health were desired. It was very important, therefore, that all reasonable items for inclusion in Cycle III be fully investi- gated and appraised as to their importance and feasibility. The determination of these refinements and the specific data desired which was obtainable by the HES type of examination was made only after extensive consultation and evaluation. Four distinct types of consultation were involved, Plan- ning the general aspects involved a continuing advisory panel of experts from various institu- tions across the country who were noted for their expertise on problems related to adolescent med- icine and to the examination of children and youths. These individuals were recognized authorities in the fields of pediatrics, maternal and child health, anatomy, child psychology, epidemiology and bio- statistics, preventive medicine, and growth and development, It was the function of this panel to examine each proposed item for inclusion or ex- clusion in the examination portion of the survey; the final responsibility, of course, remained with the Division of Health Examination Statistics. The persons who constituted this panel are: Dr. Peter V. V, Hamill, Chief Medical Advi- sor, Health Examination Survey, U.S. Public Health Service, Chairman Dr. Forrest H. Adams, Professor, Pediatrics (Cardiology), University of California at Los Angeles Dr. Nicholas G. Alexiou, Associate Profes- sor, Maternal and Child Health, Johns Hop- kins School of Hygiene and Public Health Dr. Robert Haggerty, Chairman, Department of Pediatrics, University of Rochester Dr. Paul Harper, Chairman, Department of Maternal and Child Health, Johns Hopkins University Dr. Felix Heald, Chairman, Department of Pediatrics (Adolescent Medicine), George Washington University Dr. Robert W. McCammon, Director of Child Research Council, University of Colorado Dr. Sarah Idell Pyle, Anatomy (Brush Foun- dation), Case Western Reserve University Dr. Robert Reed, Professor of Biostatistics (Harvard Growth Study), Harvard University School of Public Health Dr. Kenneth Rogers, Professor of Preventive Medicine, University of Pittsburgh Dr. Carl S. Shultz, U.S. Public Health Serv- ice (School Health) The second type of consultation involved a series of ad hoc meetings onthe more specialized aspects of the examination. Included were one or more meetings on examinations of vision, endo- crine assay, body architecture, nutritional ap- praisal, and exercise capacity. These meetings generally involved one or more of the experts on the continuing panel with numbers of other ex- perts in connection with specific fields. These persons were drawn from other parts of the Pub- lic Health Service and other government agencies, as well as from universities, and research in- stitutes throughout the country. The third type of consultation involved many visits by individual HES staff members to specific individuals and institutes across the country in order to discuss problems with regard to particu- lar, proposed parts of the examination, The fourth type of consultation was with the Advisory Committee to the Surgeon General on the National Health Survey. This is a formally constituted body, represented by a wide range of interests in the health field. Development of Specific Areas In the consideration of items for inclusionor exclusion in the physician's examination and other specific areas, certain guidelines were estab- lished. These were as follows: 1. Procedures should be included which will identify youths who are not physically qualified to participate in certain parts of the overall examination. 2. Diseases or deformities with an expected frequency of less than 1 percent should not be included. An item of such a small expected frequency would be subject to too great a sampling error and, in addition, would not return a yield justifying the money and effort. 3. All items should be judged from the prac- tical side with respect to time required for administration; personnel require- ments with respect to type, number, and special training required; space; equip- ment maintenance and service; impact on the examinee; and cost. 4. The item should be of special interest and applicable to the entire sample. 5. Proposed items should be evaluated to identify those which may affect or be re- lated to other data included in the exami- nation, Many items were suggested for inclusion. Those that met the above criteria were subjected to further consultation and to preliminary studies and tests, some of which were quite involved and others, fairly limited. In a few instances, it was possible to take advantage of work that had al- ready beert done in some other connection. Thus, one of the important areas of interest concerned the levels of auditory acuity. It had been recognized that there was need for new standards with respect to hearing levels in youths just as there was for younger children. The American Academy of Ophthalmology and Otolaryngology Subcommittee on Hearing in Children, under the Chairmanship of Dr. Raymond E. Jordan, continued to work on the development of such new standards. This group had carried out a series of studies of school children and youths in the Pittsburgh area, had developed the detailed content and form of the examination and kinds of equipment required, and had acquired considerable experience in measur - ing auditory acuity in children and youths. This group continued their interest in the survey be- cause of the opportunity to establish norms for the total national population. From the viewpoint of the Health Examination Survey, the work which this subcommittee had completed provided extremely valuable develop- mental work. Arrangements were continued from Cycle II for the executive director of the Sub- committee on Hearing in Children, Dr. Eldon Eagles, and later for Dr. Jordan, to serve as consultant to the Health Examination Survey. The audiometric portion of the third cycle, as well as the second cycle examination, was based on the work done in the Pittsburgh studies. Dr. Leo Doerfler, working with the Subcommittee on Hear - ing in Children in this study, supervisedthetrain- ing of technicians for the Health Examination Survey. Mr. Kenneth Stewart, in charge of the Acoustics Laboratories, University of Pittsburgh, agreed to continue, as in Cycle II, the calibration of the instruments to be used and to do the field sound pressure level surveys as needed. Various other benefits have accrued to the program as a result of the cooperative arrangement, In this instance the survey had essentially no develop- mental work to do because this had been done in connection with the subcommittee activity. Because of reportedly large increase in the incidence of myopia at or around puberty, it was + decided to enlarge the visual acuity test used in Cycle II, to include the use of a set of trial lenses to obtain estimates of the prevalence and severity of myopia and to test for both uncorrected acuity and acuity with the existing correction (for which the prescription is obtained objectively by a len- someter). This new battery of tests was worked out with the help and counsel of Dr. J. Theodore Schwartz, ophthalmologist-epidemiologist at the National Institute of Neurologic Disease and Blind- ness, and Dr. Herbert A, Urweider of George Washington University School of Medicine. A fea- sibility study of this new battery of tests was done at the National Training School for Boys in Wash- ington, D.C. under Dr. Urweider's direction. Also under Dr. Urweider's direction, validation studies of both the trial lens test for myopia and the lat- eral phoria tests were done midway in Cycle III, in Chicago, Illinois. Each of the approximately 100 youths in the study was given the regular Cy- cle III examination and then a thorough clinical examination for lateral phoria and myopia, the latter under cycloplegics, to determine the extent of agreement between a regular clinical examina- tion and the survey tests, It was decided to continue for adolescents the measures relevant to intellectual and personality growth and development that were comparable to those used in the children's examinations of Cycle II with only slight modifications for the difference in age. Hence, much of the developmental work started in Cycle II was applicable or could be continued in Cycle Ill. For example, the contract study to develop recommended methods of eval- uating and analyzing the results of the modified Thematic Apperception Test started in Cycle II was continued. This study is being done under the direction of Dr. S. B. Sells of the Institute of Be- havioral Research, Texas Christian University. A contract study to further validate the Wide Range Achievement Test for children 6-17 years of age was completed under the direction of Dr. K. Warner Schaie of West Virginia University. Results of the study have been published in the methodological series of reports from the NCHS. Because of the interest indicated indetermi- nation of the level of illiteracy in various sections of this country and the lack of an instrument suit- able for survey use, a special brief reading and writing test of literacy was developed by Thomas F. Donlon and W. Miles McPeek of the Education Testing Service at Princeton, New Jersey under contract with the HES, This test is described in another publication in the methodological series of the Center. *? In 1962, with the national interest in physical fitness of U.S. children, it was decided to try to measure the physical fitness of the Cycle II sub- jects utilizing a bicycle ergometer.’ For avari- ety of reasons, this test did not prove to be en- tirely satisfactory for use in Cycle III. Under a contract from the HES, Dr, Henry Taylor and his staff at the University of Minnesota Laboratory of Physiologic Hygiene, developed a new ''sub- maximal exercise tolerance test" involving walk=- ing on a treadmill at a 10 percent grade at 3.5 miles per hour, with the subject's pulse rate and electrocardiographic response continuously mon- itored by a cardiotachometer connected to the subject by precordial leads. Further calibration and validation of this testis continuing atthe pres= ent time. The body measurements chosen for Cycles I and II were mostly determined by those interested in human engineering data. However, it was de- cided for Cycle III that accurate biologic data on growth and development in U.S. children had a higher priority than human engineering data, so the battery of body measurements is basically the traditional anthropometry used in the longitudinal studies of growth and development conducted in this country over the past 40 years. This new bat- tery was constructed after several ad hoc meet- ings of those most experienced in the field of an- thropometry and growth and development with the advice of Dr. Francis E. Johnston, Department of Anthropology, University of Texas. After some feasibility and validation studies undertaken by Dr. Johnston as consultant to the survey in an- thropometry, Dr. Johnston also trained the tech- nicians and periodically supervises their perfor- mance. Altering the primary objective of the body measurements created a conflict of interest be- cause it was also desired to maintain continuity of data from ages 6 through 79 years. The com- promise reached was to develop regression equa- tions to predict the human engineering parameters used in Cycles I and II from the new set of more biologically oriented measurements. A few of those which defied good prediction were carried on in the Cycle III battery. Investigations were conducted regarding the problem of developing a satisfactory blood col- lection technique for this age group and examina- tion setting. The optimum amount which would not have an emotional impact upon the examinee and which would not affect his performance in any of the procedures to follow, was desired. The amount of usable blood that could be drawn posed a lim- iting factor on the number of blood chemistry tests that could be performed and made a difference in accepting or rejecting an entire possible area of the examination such as the nutritional assess- ment. Logistical problems alsohadto be resolved involving the handling, separating, and packaging of drawn blood so that there would be a minimum of blood loss and packaging error. For the refrig- erated but unfrozen bloods, time from shipment to delivery was critical, sothatarrangements had to be made with postal authorities to assure prompt delivery to the laboratories in order to avoid spoilage. Drs. Bernice Cohen and Wilma Bias of the Johns Hopkins Immunogenetics Laboratory and Dr. Gerald Cooper at the Communicable Disease Center, Atlanta, Georgia, assisted the HES by advising and participating in feasibility studies and providing their laboratory facilities under contract for the subsequent determinations. Early in the planning and development of Cy- cle III, it was recognized that an accurate nutri- tional appraisal would be a valuable and useful piece of information to develop. Consequently an extensive series of ad hoc meetings, consulta- tions, and pilot studies of feasibility and valida- tion was undertaken. The uniqueness of this adoles- cent age group added a special interest to the undertaking because of the increased nutritional demands associated with the rapid growth of adolescents coupled with the legendary poor die- tary habits and erratic sleep and energy expendi- ture patterns of adolescents. On the other hand, however, the great physiologic and maturational heterogeneity of this group would greatly multiply the problems arising from sample size in subse- quent analysis of the data. A full nutritional profile would have three main parts: a biochemical appraisal, of blood and urine specimens, a clinical appraisal, and a di- etary intake survey. The first two constitute the assessment of the subject's current nutritional status, while the latter attempts to reconstruct the dietary pattern of the individual for the past X months or years. After extensive study and exploration of all available leads it was finally decided to drop the full nutritional profile from the Cycle III examination for reasons both logis- tical and technical. Although rejecting the full appraisal as neither precise enough nor workable on our sample size, a variety of items are obtained in the examination which more or less impinge upon this question and which can eventually be drawn into a unified report: namely, hemoglobin and hematocrit; skeletal age and bone density; ex- tensive anthropometry (especially height, weight, and skinfolds); general assessment by a trained physician looking especially for stigmata of mal- nutrition; total serum cholesterol, protein bound iodine, and special evaluation for goiter; and a general clinical assessment of stage of matura- tion and general growth. Because of the problem in silent urinary tract infections in women and the greatly increas- ing frequency at puberty, a screening test for girls was devised with consultation and assistance from Dr, Calvin M. Kunin, University of Virginia. Dr. Kunin also provides the necessary continuing su- pervision and his laboratory facilities are used for identifying and typing the resultant organisms. Another area of considerable interest, which after considerable study had to be limited in scope, was a full endocrine profile. Because of the cost, difficulty in ensuring adequate laboratory deter- minations, and several severe logistical obsta- cles, this was reduced to determination of protein bound iodine and the future determination of plas- ma testosterone in boys. The principal logistical stumbling block was obtaining a 24-hour or even a 6- or 8-hour urine specimen of reliable quality in our operation. A final example of "failure" after much study was an exercise tolerance test which would pro- vide a direct measure of maximum oxygen con- sumption and production of carbon dioxide in order to obtain the respiratory quotient as an index of the metabolic load placed on the subject. This pro- cedure had to be dropped from inclusion in the examination because the testing equipment proved to be too bulky for the trailers, too complex to maintain, and too delicate to withstand the rigors of transportation. The areas of health information and attitudes, behavior standards, educational goals, and opin- ions of self are but a few among many areas per- tinent to any study of adolescent health. A set of thrée questionnaires to obtainthese and other data was developed by the HES staff along with consul- tation and advice of the advisory paneltothe sur- vey and others, such as persons from the National Institute of Mental Health. The resulting question- naires were the Medical History of Youth-Parent (appendix IB), Health Habits and History-Youth (appendix IC), and Health Behavior (appendix IE). The key factors leading to the decision to utilize three questionnaires was the realization that for some items of information the parent would be the best provider of information, while for others it would be the youth. In addition, certain items asked of the youth would be better answered at the ex- amination center. It would also be possible to pro- vide for study, similarities and differences be- tween youth and parent on certain "comparison" items such as educational goals and behavior standards. Following the pretest at Detroit, Michi- gan, discussed in the following section, a contract was entered into for further testing and develop- mental work of these forms. Pilot Testing In July 1964, the first of three separate pilot test operations was conducted in the New York area, the nineteenth location in Cycle II. It was acknowledged by this time that the tests, proce- dures, and forms for the third cycle would be similar, in many respects, to those of Cycle II. One purpose of this first pretest was to deter- mine particular Cycle II procedures or tests which might be inappropriate or require further investigation or development and modification prior to a later and more formal pretest when the other examination elements were more firm. An additional purpose was to obtain a rough indica- tion of what might be expected inthe Cycle III age group with respect to response and cooperative- ness. Information from this would indicate the desirability of initiating methodological research into factors affecting motivation of teenage youths in participating in a health examination survey program. Ninety-three youths were examined in the New York pilot test. Among the procedures that were new from Cycle II was a venipuncture to determine the feasibility of this operation in the 12-17 year age group; a revised medical history form; a group of questions in the area of personal health habits and behavior to determine thereac- tion of youths to these questions and to establish whether any such set of questions should be in- cluded in the third cycle; and a brief (2 to 3 min- utes) exit interview, conducted by a consultant on adolescent behavior, which consisted of asking the examinee his or her reaction to the tests admin- istered and what portions of the examination the examinee felt should be eliminated or modified to make it generally acceptable to the Cycle III age group. The objectives of this pretest were fully real- ized. In addition, other important aspects relative to planning the third cycle which had not been an- ticipated were also brought to light. Important among these was need for changes in furniture, equipment, and space requirements within the examination center; changes in the wearing ap- parel for the examination; desirable scheduling arrangements; and optimal conditions for obtain- ing cooperation. In April and May 1965, a second pretest of the survey was carried out in Detroit, Michigan. The examination in the trailers had two main ob- jectives: to solve internal logistics problems such as length and sequence of different items of the examination (and the effect of one procedure on a subsequent one, for example, the exercise and the psychological tests) and to field test various ex- amination procedures. First among these were various procedures for the collection of urine specimens for bacteruria among the girls; theat- tempted collection of an accurate timed and re- liable 6-hour urine specimen for nutritional and endocrine determinations; various parts of the highly structured physician's examination such as nutritional appraisal, acne grading, and objective assessment of stage of sexual maturation; field testing the new treadmill and cardiotachometer (the instrument aspect and also varying duration and intensity of the test); and the testing of a var- iety of techniques for optimal blood collection and handling and packaging. A complete testing was conducted of all field procedures relating to sample identification, Bureau of the Census house- hold interviewing, followup interviewing and per- suasion by Health Examination Representatives (HER's), administrative records control, trans- portation, and collection of data from schools. A medical history questionnaire to be completed by the parent and two questionnaires involving health history and behavior to be completed by the youth were also tested. A total of 131 youths were ex- amined during this pretest. Following completion of the developmental work, indicated as a result of the first two pre- tests, a full-scale pretest was conducted in Wil- mington, Delaware, during January and February 1966, at which time 163 youths were examined. As will be discussed ina later section, the sample design of Cycle III for various reasons called for the utilization of the same sample areas and hous- ing units of the previous cycle. Wilmington, which in March and April 1963 had been the final pre- test area for Cycle II, was therefore ideally suited for the final pretest of Cycle III. As such, it was possible to obtain some insight into problems of response associated with persons subjected to both surveys; an estimate of the number of Cycle II sample youths who would fall into Cyclelll; the reaction of local societies and school officials to a second survey after about 3 years; and an esti- mate of the number of sample youths that could be produced from the Cycle II sample design. The conditions under which this pretest was conducted attempted to simulate the operation of a regular Cycle III location. Between this pretest and the first location of the actual Cycle III data collection, the technicians received further training in the areas of body measurements and audiometry and in techniques of the use of special equipment torecordon mag- netic tape the results of electrocardiograms and spirograms. The nurse also received further training in the collection and culturing procedures of the urine specimen, A ''dressrehearsal' of ex- amination procedures was held at the first stand of Cycle III, Charleston, South Carolina; at this time, 46 youths were examined. Members of the advisory panel visited the examination center to observe and give their final approval to the operation. THE SAMPLE DESIGN Similarity to Cycle II The sample design of Cycle III is similar to that of Cycle II in that it utilizes the same 40 sample areas and the same segments. The deci- sion to incorporate this feature into Cycle III was not made prior to the selection of the second cycle sample although it is consistent with the early concept of a single program for 6-17 year olds. The final decision to utilize this identical sampling frame was made during the operation of the second cycle program. This decision was based on the following considerations: 1. There would be an increase of information, since some of the children examined in Cycle II would also be examined in Cycle III. The group of examinees included in the overlap would provide longitudinal data which would add greatly to the study of growth changes. It was recognized that the loss of some individuals through popula- tion mobility would keep the subset ex- amined in both cycles from being a com- pletely unbiased sample, but it was felt the advantages outweighed this. 2. Cost of selecting a new sample would be eliminated. 3. An expected high correlation within the segments between the expected number of youths in Cycle III and the number of sample children in Cycle II. 4, Gains would be produced in the case of field operations. Addresses would be known, a large number of the sites used for examination centers in Cycle II would be available, and contacts with State and local officials, to explain our program and obtain their approval, could be made by mail rather than by personal visit. The sample design has been essentially simi- lar for all three cycles in that each has been a multistage, stratified probability sample of clus- ters of households in land-based segments. The successive elements for this sample design are primary sampling unit, census enumeration dis- trict, segment (a cluster of households), house- hold, eligible youths and finally, the sample youth. Every eligible youth within the defined population has a known and approximately equal chance for selection into the sample. : A description of the Cycle II sample design is presented in another report.** It also discusses the problems of and consideration given to other types of sampling frames, cluster versus random sampling, and whether or not to control the selec- tion of siblings. It is felt, therefore, that an ab- breviated discussion of the Cyclell sample design and the minor modifications required for Cycle II is sufficient for the purpose of this report. The Cycle II sample design was developed from a set of specifications which described the requirements and limitations placed on it. The general factors dictating the design specifications were those relevant to the specific survey ob- jectives and operational considerations. Those of primary importance and relevant to both Cycles IT and III included the following: 1. The target population will be defined as the civilian, noninstitutional population of the United States, including Alaska and Ha- waii, between the ages of 6 and 11 years for Cycle II, 12 and 17 years for Cycle III, with the special exclusion of children re- siding on any reservation lands set aside for the use of American Indians. This ex- clusion is due to operational problems en- countered in Cycle I, 2. The time period of data collection should be limited to about 3 years. 3. The examination objectives will be pri- marily concerned with factors of physical and intellectual growth and development. 4, The length of an individual examination will be between 2 and 3 hours. Approxi- mately 12 examinations will be dorie each day. 5. Examinations will be conducted in a spe- cially constructed mobile examination center, 6. Ancillary data will be collected through the use of questionnaires and other rec- ords. These will consist of a household questionnaire, medical history question- naire, school questionnaire, and copy of the birth certificate. 7. The size of the sample must be sufficiently large toyield reliable survey findings. The numbers involved will permit a general analysis by broad geographic region, pop- ulation density groups, and other major subgroups such as age, sex, and limited sociodemographic factors of the total sample. 8. The size of the sample will also be in- fluenced by certainadministrative consid- erations and by the available budget which, in addition to conducting collection activi- ties, must permit simultaneous activity in analysis and publication of findings from other cycles and preliminary planning for the next cycle. The steps of drawing the sample were car- ried out jointly with the Bureau of the Census, The starting ‘points were the 1960 decennial census lists of addresses and the nearly 1,900 primary sampling units (PSU's) into which the entire United States was divided. Each PSU is either a standard metropolitan statistical area (SMSA), acounty,or a group of two or three contiguous counties. These PSU's were grouped into 40 strata so that each stratum had an average size of about 4.5 million persons. This grouping was done in a manner which maximized the degree of homogeneity within strata with regard to the population size of the PSU's, degree of urbanization, geographic prox- imity, and degree of industrialization. The 40 strata were then classified into 4 broad geographic regions of 10 strata each and then within each re- gion, cross-classified by four population density classes and rates of population change from 1950 to 1960. Using a modified Goodman-Kish con- trolled-selection technique, one PSU was drawn from each of the 40 strata. The sampling within PSU's was carried out in several steps. The first was the selection of census enumeration districts (ED's). These ED's are small, well-defined areas of about 250 housing units into which the entire Nation was divided for the 1960 population census. Each ED was assigned a "measure of size' equal to the rounded whole number resulting from a "division by nine'' of the number of children, aged 5-9, inthe ED at the time of the 1960 census. A sample of 20 ED's in the sample PSU were selected according to a sys- tematic sampling technique with each EDhavinga probability of selection proportional to the popula- tion of children 5-9 years at the time of the 1960 census date, From each ED a random selection of one measure of size (segment) was taken, Minor changes required inthe CyclelIll design were that it be supplemented for new construction to a greater extent than had been necessary in Cycle II, and that reserve segments be added. Although it was the plan for Cycle III to use the Cycle II segments, it was recognized that within several PSU's additional reserve segments would be needed to avoid the risk of having an insuffi- cient number of examinees. This was prompted by the fact that four of the PSU's in Cycle II had yields of less than 165 eligible children and sev- eral others were marginal in their yield. In ad- dition, there was a 3-year interval between Cycle II and Cycle III, so that it was quite possible for some segments to have been completely demol- ished to make room for highway construction or urban redevelopment, 10 Subsampling The time available for examinations ata par- ticular location, or stand as they have been des- ignated, is necessarily set far in advance of any preliminary field work at the stand. Therefore, the number of examinations that can be performed at a particular location is dependent upon the number of examining days available. At the majority of locations the number of days avail- able, excluding Saturdays, is 17. At the rate of 12 examinations each day, this provides for 204 examination slots. Examinations are conducted on Saturdays if, for some reason, itis necessary. Because of rescheduling for cancellations or no- shows the maximum number of youths that is considered for inclusion in the sample is 200. When the number of eligible youths exceeds this number, subsampling is performed to reduce the number to manageable limits. This is accom- plished through the use of a master list which is a listing of all eligible youths in order by seg- ment, serial (household order within segment), and column number (order in the household by age). After the subsampling rate has been de- termined, every nth name on the list is deleted, starting withthe ythname, y beinganumber be- tween 1 and n selected randomly. Youths who are deleted from the Cycle III sample but who were examined in Cycle II as well as any twin who may have been deleted are, if time permits, scheduled for an examination for inclusion in the longitudinal study portion or twin study portion of the survey. OTHER SAMPLING ASPECTS Sampling Features of the Examination The sampling aspects of the survey are not restricted to choosing the sample persons and having them participate in the examination. The conduct of the examination itself has numerous sampling features which should be mentioned here. Examinations will be conducted in 40 differ- ent locations throughout the United States by ap- proximately 35 different physicians and five den- tists. There will be approximately 12 technicians performing various procedures and 12 psycholo- Table 1. Cycle III schedule of stand operations, HES, 1966-70 Stand number Location! PON H e HFOWVWRNOULPEWNHROWVONOULAWN HF Charleston, South Carolina---==--=-- Ashtabula, Ohio=--===mcemccccaaaan Poughkeepsie, New York------------ Portland, Maine~=-====-=cecemmeua- Boston, Massachusetts~------=----- Philadelphia, Pennsylvania-==-===-== Ottumwa, Iowa====m=mm-=mmcecemaaa= Denver, Colorado---===c-=c-cce-n-u- Lamar, Colorado---===-=--ceceecceu-- Los Angeles, California--=--=====- Los Angeles, California----===---- San Francisco, California--------= Mariposa, California--------=------ Moses Lake, Washington------------ Minneapolis, Minnesota=-=--=-==-==-- Neillsville, Wisconsin-=-=-==e-e-= New York, New York-=-=-eeeeececaaa- New York, New York-====-eeemececan- Baltimore, Maryland--------------- Sarasota, Florida==--===cemececaaa- Atlanta, Georgia~=----=-cemceeaaa= Date of field operations ———— March-April 1966 ==== April-May -——— May-June -— June-July — July-August i min August-September ———— September-October -—— October-November — November -December ---- December-January-February 1967 — January-February-March -==-= February-March-April ---- March-April-May ~==-=- April-May-June -=-=-- May-June-July -===- June-July-August ———— August-September-October —— September~-October~November ——— November -December -=-=-- January-February 1968 -=== February-March 22 Birmingham, Alabama~--=-===--cceccenaa= March-April 23 Barbourville, Kentucky-=---===ceccemu- April-May 24 Cleveland, Ohio===-==-eecceccmcnceeaa- May-June 25 Chicago, Illinois=--==--c-ceccenccacn= June-July-August 26 Grand Rapids, Michigan--=--=-=v-rceeu= August-September 27 Des Moines, Iowa--=-====---eccecccaaaa= September-October 28 Wichita, Kansas=====--ccccccmccccccan= October-November 29 Marked Tree, Arkansas---------=-ceccea- November -December 30 San Benito, Texas======mmmmmemeeenen—— January-February 1969 31 Houston, Texag~====mrmmmmeemnmnmmmmwnnen January-February-March 32 Detroit, Michigan=-=======-ccceccunua- March-April 33 Port Huron, Michigan-----==ccceccecea= April-May 34 Beattyville and West Liberty, Kentucky- May-June-July 35 Allentown, Pennsylvanig----=--=cc-e--- July-August 36 Manchester and Bristol, Connecticut=--- August-September-October 37 Newark, New Jersey-=-===cc-ceccenenn=- September-October-November 38 Jersey City, New Jersey==-====-=-ccewa= October-November -December 39 Georgetown, Delaware=---=-=c-mceemeuc= January-February 1970 40 Columbia, South Carolina-=---===--==c=- February-March lStand locations are cities or towns in which trailers were located. Sample areas from which examinees are drawn for the stand consisted of the PSU's which may have in- cluded several counties. gists administering psychometric tests. Ideally, each examinee should be assigned to the particular parts of the examination on a random basis with respect to time, place, and examiner, This is obviously impossible. Therefore, if there areany peculiarities in the conduct of a part or parts of the examination procedures, difficulties with equipment, or changes in the standards of the lab- oratories doing blood chemistry analysis, they may be reflected in the examination findings as a place peculiarity. Stand Sequencing and Scheduling In all cycles of the Health Examination Sur- vey, the scheduling of stands has been deliberately arranged so that the North is avoided in winter and the South in summer, This is a fairly obvious operational necessity as it would be quite imprac- tical to conduct a mobile examination survey such as this in the northern States in the middle of the winter. The schedule of stands for the thirdcycle is shown in table 1. While this type of scheduling is desirable from an operational point of view, it can produce certain limitations on the examination data. Any characteristic under study which may have a sea- sonal variation will be difficult to interpret by geographic region. For example, if persons inall parts of the country weigh more in winter than in summer, the mean weight of northerners would be underestimated and that of southerners overesti- mated. Possibilities such as these must be taken into account in analysis of the data. The serious- ness invoked by such a scheduling arrangement, however, is not considered to be too serious a limitation in either Cycle II or Cycle III. Most of the characteristics of the examination in the 6- 17 age group are not likely to exhibit any marked seasonal variation. Even in Cycle I, where the focus of the examination was on chronic condi- tions in the adult population, this was not con- sidered to be too serious a problem. This would not be true if the examination, in any of the cycles, attempted to obtain estimates of acute conditions such as respiratory disorders. An important consideration in sequencing stands was economy of operation. Efforts were made to follow the seasonal pattern described above, with a minimal amount of travel necessary in moving from one stand to the next by sequencing with regard to geographic proximity. Another con- sideration was to minimize the range of the time interval between the collection of Cycle II andthe Cycle III data at each location. The map (fig. 1) shows the sample areas and itinerary of Cyclelll, Individual stand time schedules, featuring the var- ious operational aspects involved in conducting the examinations at a particular stand, were alsore- Figure |. Map showing sample areas and itinerary: Health Examination Survey Cycle III. 12 quired in the development of the sequencing. Time allowances were based on the distance between stands and therefore the time required for move- ment of the trailers and personnel between stands, the time required for Census interviewing, HER followup, trailer setup, staff setup and dry runs, staff vacation periods, and at most stands, 17 days for examinations. Schedules for three of the stands are shown in table 2. ADVANCE ARRANGEMENTS Professional Relations Before the interviewing or examination pro- cedures of the Health Examination Survey can be started in a sample area, certain types of ad- vance arrangements are necessary. Essentially, they are of three different types involving pro- fessional relations, public relations, and arrange- ments for the logistical requirements of the survey. The conduct of the survey in any specific area is the responsibility of the U.S. Public Health Service, as distinct from the Stateor local health authorities, or others in the area. In all three cycles, however, it has been our policy to fully acquaint the State and local health depart- ments, and the medical, dental, and osteopathic professional organizations in the States and in the communities with the HES objectives and method of operation. In addition, since both Cycles II and III involve the examination of school chil- dren, the State and local officials concerned with public schools are also contacted, as are the ap- propriate local and diocesan officials of the paro- chial schools. In Cycle II, contacts were made initially by letter or telephone giving some information about the program and arranging for a personal visit to discuss the plan in detail. A senior medical advisor to the survey visited the State medical societies, health authorities, and educational of- ficials. The dental advisor informed the officials of the dental association by mail and frequently arranged a personal visit as well. The visits to the State school officials were always preceded by a general information and introductory letter from the U.S. Office of Education, which had been kept informed throughout the planning of the program. Table 2, Excerpt from HES—III schedule of stands Stand #30 - San Benito, Texas 1/3-2/14 (944 miles) Office setup=====-==cecaax 1/3 Friday Census interviewing------- 1/6 Monday HER followup=-====mmeemua-x 1/13 Monday Trailer arrivale-e-meeceneea 1/14 Tuesday Trailer setup----========= 1/15 Wednes- day Staff setup and training-- 1/20 Monday Dry runs=---=--=------e--- 1/21 Tuesday Examinations-------=cec--x 1/22 Wednes- day-2/13 Thursday Dismantle-----=-cccmmmnanan 2/14 Friday In transit-----e-ceccecana 2/14 Friday Stand #31 - Houston, Texas 1/31-3/19 (353 miles) Office setup-=--===c=mmeu=-- 1/31 Friday Census interviewing=------ 2/3 Monday HER followup=-======meeeen 2/10 Monday Trailer arrival----------- 2/17 Monday Trailer setup----=-=-===-== 2/18 Tuesday Staff setup and training-- 2/19 Wednes- day Dry runs==-=-----eecomeeax 2/20 Thursday Examinations--=--=-cceceux 2/24 Monday~- 3/18 Tuesday Dismantle--==--cccemcmeanx 3/19 Wednes~- day In transit=-----ececccceceaan 3/19 Wednes- day Stand #32 - Detroit, Michigan 3/7-4/21 (1,274 miles) Office setup=--==ememeeuun 3/7 Zriday Census interviewing---=---- 3/10 Monday HER followup=--==meeeeneen 3/17 Monday Trailer arrival----------- 3/24 Monday Trailer setup------------= 3/24 Monday Staff setup and training-- 3/25 Tuesday Dry runsS=--------eececeoaa 3/26 Wednes-~ day Examinations------=-cccu-- 3/27 Thurs- day-4/18 Friday Dismantle----==-cmceceaaan 4/21 Monday In transit------==--ceca-- 4/21 Monday It has been mentioned previously that the sample areas in Cycle II are also being used in Cycle III. In the present cycle, therefore, it was felt that personal visits to the above officials were not required in all cases. Instead, letters are 13 mailed approximately 8 weeks before interview- ing procedures are to begin, explaining the pro- gram and reminding them that the HES had visited the sample area several years before to collect similar information on the health of children ages 6-11 years. Also included is a copy of a resolution passed by the American Medical Association House of Delegates expressing their approval of the survey and recommending cooperation. A sec- ond followup letter with supplemental information about the survey is mailed about 1 week before interviewing begins. At this time, letters and lit- erature describing the survey are also mailed to local officials such as the mayor, the Chamber of Commerce, and law enforcement officers, At the State and local levels, support of the survey has been manifested in the cooperation ob- tained in informing physicians of the survey. Frequently this is done by means of an article in a professional publication distributed to all phy- sicians in the area such as the monthly bulletin of the county medical society. Correspondingly, communications from the dental society are usu- ally sent to its members, and the superintendent of schools will usually send letters to school officials who will be contacted later by a repre- sentative of the survey. Public Relations General news releases explaining the pro- gram are prepared for each sample area and are distributed to local news media. The release is timed to coincide with the start of Census inter- viewing. As a result, local newspapers at most of the locations publish items concerning the pro- gram. No special effort is made tohave radio and television stations publicize the survey, but at some locations, members of the staff have been interviewed by these media and film has been taken to be shown on television. Under no cir- cumstances, however, are pictures or films taken of any sample examinee since this would be a breach of our promise of confidentiality. Sample households having a mailable address (house or post office box number) are sent an "advance" postcard by the Bureau of the Census several days before the Census personnel begin interviewing. This card informs the household members that a Bureau of the Census interviewer 14 will be calling at their home within the next few days in connection with a survey being conducted in the area for the U,S, Public Health Service, Logistical Arrangements Four to 6 weeks prior to the start of a stand a member of the HES field staff, the Field Opera- tions Manager (FOM), visits the sample area to make physical arrangements for the Mobile Ex- amination Center and the administrative office, to personally contact local health and school of- ficials, and to initiate the many logistical actions required for the survey. The selection of loca- tions for the examination center and administra- tive office are considerably simplified in Cycle II, since in most sample areas the same sites used in Cycle II are available, If for some reason the previous examination site is not suitable, the following items are considered in the selection of a new one: 1. Location of sample households and trans- portation arteries. 2. Community attitude (if any) toward the location. 3. Proximity to power, water, and sewer connection, 4, Reasonably free from noise and/or exces- sive vibration. 5. Availabilityof living accommodations for the staff within a reasonable distance. 6. Adequate space to accommodate trailers and cars of staff. 7. Availability of office space for the ad- ministrative office in close proximity to the examination site. During this visit to the sample area, the FOM also arranges for power hookup and services for electricity, water, sewerage, telephone, transpor- tation, and laundry. Any other logistical arrange- ments required before the arrival of the mobile examination center and the staff, are also taken care of at this time. Within the time allowed, he visits as many as possible of the city and county school superintendents whose authority extends over schools which the sample youths attend. HOUSEHOLD INTERVIEWING PROCEDURES Census Interviewing Trained Bureau of the Census personnel call on all housing units contained in the segments of the sample area to determine their household com- position and to obtain demographic and other data if the household contains any eligible youths be- tween 12 and 17 years inclusive. They pave the way for the HES interviewers who subsequently visit the household. Each of the households should have received the advance postcard from the Bu- reau of the Census informing them of this visit, The front of the household questionnaire, shown as appendix IA, contains standard Census identi- fication entries related to the housing unit, space for recording information on calls, and a section concerning a Medical History Form which is left if the household contains any eligible youths. On the inside of the questionnaire, questions 1-6 identify all persons living in the household, their relationship to the head of thehousehold, and their age, race, and sex. If the household does not con- tain any youths between the ages of 12 and 17 in- clusive, the interview is concluded. If the household does contain a youth eligible for inclusion in the survey, the remaining ques- tions are asked only of the parent or guardian of the youth. A callback is made by the Census in- terviewer if a parent or guardian is not present initially. At the end of the interview, the inter- viewer leaves a medical history form with the parent or guardian to be completed for each eli- gible youth, This form is shown as appendix IB. The interviewer explains that a representative of the U.S. Public Health Service will come to the house in a week or so to pick up the completed form. The interviewer also inquires asto the best time of day for the representative to pick up the form. Occasionally the Census interviewer will in- terview a household which contains an eligible youth 12 through 17 years of age but in which there are no parents or guardians, e.g., al6or 17 year old who is married and living with his/her spouse. In such instances, only the identification items of the housing unit are completed on the front of the questionnaire (question 14 is omitted), and on the inside and back of the form only questions 1-7, items C and E, and questions 13-16. Itis explained that the Public Health Service would like to send the medical history form to the parents of the eli- gible youth concerning his medical history and some questions concerning his mother. The eli- gible youth is asked for his parent's name, com- plete address, and telephone number. This infor- mation is then given to the HES staff to followup and mail the questionnaire. The role of the Census interviewers is ended after all household question- naires have been edited by the Census supervisor for omissions or inconsistencies and then turned over to the HES field management office, HES Interviewing From the household questionnaires a master list is prepared which lists the name, age, sex, and household identification of each eligible youth. An eligible number (1, 2, 3, 4, etc.) is assigned to each youth, If the number of eligible youths does not exceed the maximum number allowable, then sample numbers are assigned beginning with the first youth on the list. If the number of eligible youths exceeds the number allowable, then the sub- sampling procedure described in an earlier sec- tion is performed. Youths remaining after sub- sampling are then given Cycle Ill sample numbers. If examination time allows, as many as possible of the youths deleted from the sample through the subsampling procedure who were (a) examined in Cycle II or (b) are a twin whose twin sibling is a sample youth, are also given sample numbers but in a different series from the Cycle III numbers. The former group of youths (a) are examined as part of the longitudinal study aspect which Cycle III presents, and the latter group (b) as part of a smaller study of twin characteristics. A few days after all Census interviewing is completed and the master list prepared, HES representatives (HER's) visit all households con- taining eligible youths. This visit is designed to accomplish several things. The medical history form which was left by the Census interviewer to be completed is carefully reviewed for com- pleteness and consistency. If the form is not com- pleted, the HER attempts, with the parent's help, to complete it at that time. Except to answer any questions that the parent might have about the 15 survey, there is no further responsibility placed upon the HER with respect to the youths deleted from the Cycle III sample and not included in the longitudinal or twin studies, For the sample youths in Cycle III, deleted youths who were examined in Cycle II, and deleted twins, there is much more involved in this visit, At an appropriate point in the visit, the HER explains the program to the parent, She must be able to answer many ques- tions about the survey such as the purpose of the survey, how the sample was selected, examination content, value of the examination to the individual, and others, Obtaining agreement to cooperate by participation in the examination has not been a great problem in either Cycles II or III, Signed consents of the parent are obtained for the youth's participation in the survey, for the survey to transport the youth to and from the mobile ex- amination center, and for the survey to obtain additional information from school personnel, from a physician's, dentist's, or hospital's rec~ ords, and from other official sources such as State registrars. A school excuse form is also signed by the parent, The HER indicates to the parent that the Public Health Service will be glad to forward to the youth's physician or dentist the findings of the medical and dental examination if the parents so wish, A marital history of the par- ents is obtained and a Health Habits and History form is left with instructions that it be completed by the youth and be returned to the survey in the envelope provided before he arrives for the exam- ination, This form is shown as appendix IC, The characterization of twins as identical or fraternal is also established. Scheduling restrictions are determined and recorded for later use by the ad- ministrative office in setting up appointments. Finally, it is explained to the parent that he will be notified by the survey of the date and time of the examination, Also a leaflet is left which de- scribes the program (fig. 2). APPOINTMENT AND TRANSPORTATION PROCEDURES After all Census questionnaires have been received, the schools attended by the sample youths are identified and grouped. The Field Operations Manager contacts the School Super- intendents either in person or by telephone de- 16 pending on whether a contact was made during advance arrangements, They are informed that the program is underway in the area, which of the schools under their jurisdiction are involved, and the number of youths, If the Superintendent has not previously informed the school principals under his jurisdiction of the survey, he is asked at this time to contact those principals of the schools which contain sample youths, The scheduling and notifications of examina- tion are worked out by the field management of- fice. In preparing the schedule of youths to be examined on any particular day, consideration is given to any restrictions determined at the time of the HER interview, the distance to the exam- ination center, the school groupings, and any con- siderations the school officials may have intro- duced with regard to particular days or times, Efforts are made to minimize the transportation workload, At least 3 days before the date of the examination, an appointment slip and covering letter are mailed to the home, Entered onthe ap- pointment slip is the time, day, and date of the examination, where and when the youth will be picked up, and when he will be returned. Youths examined in the morning are usually scheduled to be picked up at home and then taken to school after the examination and a light lunch at the center. Those examined in the afternoon are scheduled to be picked up at school and taken home after completion of the examination. Escorts are provided for all youths. Usually these are care- fully selected persons residing inthe sample area with transportation secured from taxi, limousine, or small bus companies, or HER's or other HES administrative staff using government cars, There are always a number of youths who for one reason or another cancel their appointments or are not available at the time they are to be brought to the center. Those who cancel are fairly easily rescheduled for another time. Those who fail to appear without any notice of their intention to do so or change their mind about participating are followed up as soon as possible, preferably the same day. Immediate followup of these youths helps to reinforce in the sample youth's mind the importance placed on his participation. In many cases, the youth can thus be brought to the ex- amination center only a little later than the other examinees, YOU and the Health Examination Survey BACKGROUND The Health Examination Survey is part of the U.S, National Health Survey authorized by Congress in 1956 to collect in- formation about the health of Americans. Some information is collected by asking people questions about themselves and their health. Other needed data can only be obtained by an actual health examination. All information obtained from individuals by interview and through the examination is held strictly confidential. A re- port of the significant medical and dental findings is sent to the examinee's physician and dentist on request. Reports of overall findings are published for use by medical re- searchers, educators, physicians, dentists, and many public and private agencies. In 1962, the Health Examination Survey completed a study of health conditions of persons 18-79 years of age. About 7,000 adults throughout the United States participated in the special health examination which was a part of that survey, In a second cycle of the Health Examination Survey, some 8,000 children aged 6-11 years participated in a health examination designed to provide information about growth and development during these years, This was com- pleted in December 1965. In this cycle, we will be concentrating on you young people from 12-17 years of age. Some of you who were examined as 6-11 year olds may now be eligible for reexamination as part of this older group. In any event we are concerned with the health aspects of your growth and development during these important years. HOW YOU WERE CHOSEN The U.S. Bureau of the Census, working with the Health Examination Survey, has selected 40 areas in the United States which, taken altogether, represent the entire Nation. Each of these areas consists of one or more counties lo- cated in the northern, eastern, southern, and western parts of the country. Some are urban and some are rural. Within each of these 40 areas, about 600 houses are selected by scientific sampling methods. This is how we happened to come to your home, Every person 12-17 years old, living in one of these houses, automatically becomes a part of the national sample. This consists of some 9,000 young persons on whom we will obtain medical histories. This figure will then be reduced by another sampling procedure to give us a sample of about 8,000 persons to be examined. Both you and your parents have been asked to fill out a questionnaire concerning YOUR health. If you are one of those chosen, you have also been asked to participate in the examination. For this, of course, we need the written con- sent of your parents since, legally, you are a minor. CONTENTS OF THE EXAMINATION The examination, which should be an interesting and en- joyable experience for you, consists of the following: A special examination by a physician of the eyes, ears, nose and throat, heart, and nerve and muscle systems. An electrocardiogram and a phonocardiogram of the heart. (Tape recordings of electrical impulses in the heart and of the heart sounds) An examination by a dentist of the teeth and mouth, Recordings of blood pressure. Measurements of verbal, perceptual, and social skills by a psychologist. Audiometric tests for hearing performed in a specially constructed soundproof room. Tests of vision and visual acuity. An X-ray of the chest and one of the hand and wrist. An exercise test walking on a treadmill, and a grip strength test. Biological and biochemical tests on a blood sample. Measurement of breathing capacity. Height, weight, and other measurements of growth and development. The examination lasts about 3% hours. There are two ex- amining periods each day, morning and afternoon. Occasion- ally there will be an evening session scheduled. Six youths will be examined during each period. Ordinarily, there will be other young people from your neighborhood or school in your group. The examination is given in our mobile "Health Examination Center" which consists of four specially built trailers. Transportation to and from the Center will be provided by the Public Health Service. There is no cost to you for any part of this. If you are scheduled for the examination during school hours, arrangements will have been made with the proper school officials in advance. WHY YOU ARE SO IMPORTANT There are some 22 million young people between the ages of 12 and 17 in the United States. Naturally we cannot ex- amine all of them. Asa participant, therefore, you represent about 3,000 youths in your age group. Whether you have been asked simply to complete the medical history or whether you have been asked to participate in the health examination as well, you play an essential partin the success of the survey. Figure 2. Pamphlet describing the program. At the time sample youths are picked up or returned to the schools, the escorts leave with the school principal a form, Supplemental Infor- mation From School, for each sample youthin the school. The principal has been notified of this aspect of the survey before delivery of the forms and has been asked to have the form completed by the youth's teacher or whoever he believes to be the best informed respondent. Each form has the name and address of the sample youth already entered, and a preaddressed envelope is provided for its return to the survey. This form is shown as appendix ID. In those locations visited during the summer months, when school is not in ses- sion, the questionnaires are mailed to the school in the early fall with a request that they be com- pleted and returned. EXAMINATION CENTER AND FIELD STAFF As in the previous two cycles, examinations are carried out in a specially constructed mobile examination center. The center used for Cycle II required some modifications and renovations to be performed between cycles to adapt for changes in examination procedures, but the basic scheme is the same. Four large trailers are used, two are 35 feet long by 8 feet wide and two are 45 feet in length by 8 feet wide. The individual trailers are drawn by detachable truck tractors when making moves from one area to another. These trailers are set up side by side and connected by covered passageways to make the examination center. Fig- ure 3 shows the four trailers and the floor plan of each. A minimum space of 60 feetby 60 feet is required to accommodate the trailers. The sites on which the trailers are located must be as level as possible to avoid any effect on certain exam- ination procedures and must also be accessible to the truck tractors. Heating and air conditioning units have been installed to help provide a stand- ardized environment for conduct of the examina- tions. The field staff necessary to carry out the operations of the survey may be considered to consist of three elements. The first is the team of Census interviewers (usually five to seven per- sons) and a supervisor. Their work, which is described elsewhere in this report, begins on a 18 Monday, takes about 5 days to complete, and is usually 2 to 3 weeks in advance of the examina- tions, The second element consists of the admin- istrative and management personnel and the HES interviewers. The administrative staff arrive at the location and set up their office on the Friday before Census interviewing, with the HES inter- viewers arriving 1 week later, The administra- tive staff consists of two field office managers and two administrative assistants. The adminis- trative staff includes duplicate positions since their operations at anew sample area begin before all examinations at a preceding area are com- pleted. This period of overlap is in most cases 2 or 3 weeks. The third element is the examining staff operating within the mobile examination center. These include a physician, a nurse, a dentist, two psychologists, four laboratory X-ray technicians (one with supervisory responsibili- ties), and a clerical assistant. With the exception of the physician, all other members of the field staff are Civil Service em- ployees or Commissioned Officers of the Public Health Service. The examining physicianis either a senior resident or a fellow in pediatrics re- cruited from selected medical centers, medical schools, or hospitals and is generally employed only for a single sample area. A medical advisor to the survey, a Public Health Service commissioned officer, is present during the first few days of each stand to super- vise examinations by the new physician and to provide consultation on any of the other various medical aspects of the examination. EXAMINATION PROCEDURES General As discussed previously, the content of the examination was developed after extensive plan- ning, consultation, and methodologic and pilot studies, As such, it is a special examination tai- lored to the objectives and limitations of the sur- vey and is not intended to be a complete medical examination. The fact that the examination is not a substitute for a visit to one's own physician and dentist is explained to the parents of each sample youth. The findings of the physical examination are not disclosed to the youth or parent but, with the EXERCISE br penn WASH ROOM I | PHYSICAL r - EXAMINATION y | = — — | STAFF ROOM | AUDIOMETRY | ! LABORATORY | | | No. 1 ( Sr] EXAMINEE foe mete—— WASH ENTRANCE | | | id WAITING WAITING AREA AREA WAITING AREA A ww - 1 PSYCHOLOGICAL | EXAMINATION DARK ROOM | STORAGE [es I": STORAGE X-RAY PSYCHOLOGICAL EXAMINATION FLOOR PLAN DENTAL EXAMINATION Figure 3. Mobile examination center. parent's signed consent, a report is sent to the physician named by the parent. A report of the dental examination is likewise sent to their den- tist, The reports make no specific treatment rec- ommendations except to suggest, when it appears desirable, that the youth be seen before his next regular appointment, All forms being used in the examination, with the exception of those in the psychological area, are shown as appendix IF. Flow of Examinees The pattern of scheduling examinees in Cycle III is very similar to that of Cyclell. In the early pilot test work of Cycle II it was observed that the children were more at ease if a number of them came in for the examination at the same time. Another advantage of this type of scheduling was the fact that since most of the children were attending school, the problem of transportation would be facilitated if a number could be picked up at school or transported back to school at the same time. Individual scheduling of examinations would greatly complicate the problem of trans- portation. Six examination slots are available in the morning and six in the afternoon. Because of this it is necessary to vary the sequence of examina- tions, for example, the six could not be examined by one physician at the same point in the sequence of examination elements if all examinees started together, After screening all history forms, the physician sees and examines beforehand any ex- aminee whose history for cardiac or other rea- sons indicates he may be unable to tolerate the exercise test, and will exclude him from the test if necessary, Equally important is the fact that pregnancies among females be identified so they will be omitted from the treadmill test and from the chest X-ray. When the examinees arrive at the mobile units, the nurse and the clerical assistant provide a short resumé of the examination to assure the examinees that no internal or painful tests are in- volved and to place them at ease asmuch as pos- sible. Temperatures are thentaken and any exam - inee with a temperature of 100° or over is seen immediately by the physician and may be sent home at the physician's discretion. These will be re- scheduled for another date. Name cards showing 20 the examinee's name and sample number are worn during the entire examination. Special clothes are also provided. These consist of gymnasium-type shorts, a terry cloth robe, and cotton socks. Girls are also provided with a specially designed blouse. These uniforms were designed to facilitate and standardize various elements of the examination such as the physician's examination, the body measurements, and the X-rays. The flow of examinees is controlled by the daily flow chart which is designed for efficient uti- lization of staff time by specifying the sequence in which the youths are examined. The daily flow charts, one for morning and one for afternoon, are made up by the clerical assistant, Inthe prepara- tion of these charts, numbers Ithrough Vlare as- signed to the examinees. Thesenumbers, as canbe seen from the chart (fig. 4), determine the se- quence of examination procedures for each exami- nee. In the event there are fewer than six exami- nees, any of the six numbers may be omitted to obtain the examination sequence which permits best utilization of staff members. The clerical assistant has the responsibility to insure that the flow chart is followed. In addition to those discussed above, other responsibilities of the clerical assistant which should be mentioned here include recording data from the dental examination, maintaining a daily log of unusual events, reviewing completed case records for completeness and consistency, pre- paring examinee lunches and snacks, and seeing that each examinee completes a self-administered Health Behavior form (appendix IE) during some free time in the examination if it has not been completed during the psychological testing. The Examination by Physician and Nurse Prior to joining the field staff, each examin- ing physician receives brief training in special areas, especially in adolescent medicine (includ- ing maturation grading), otolaryngology, and der- matology. A medical advisor of the survey con- ducts this training with the aid of consultants in medical institutions in the Washington, D.C. area. Each Medical History of Youth form (ap- pendix IB) and Health Habits and History-Youth form (appendix IC) is reviewed by the examining physician on the day before the scheduled exami- Date A, M0 PP. M.[J 1 1 I Ii III Iv Vv vi 0 hour 2 Physician Dental and and T-1 T=-2 Nurse Vision lst hour Psychology | Psychology Dental Physician and and T=2 T-1 Vision Nurse Physician Dental T-1 T-2 and and Nurse Vision 2nd hour Psychology | Psychology Dental Physician T-2 T-1 and and Vision Nurse Physician Dental and and T-1 T-2 Nurse Vision 3rd hour Psychology | Psychology Dental Physician and and T=2 T-1 Vision Nurse 1 2 tests). HEALTH EXAMINATION SURVEY~-CYCLE III Examinee Flow Chart I and II will be boys. Temps., change clothes (except I and II who change clothes after the psychological NOTE: T-l= treadmill, body measurements and grips, X-ray, height-weight. T-2= audio, spirometer, ECG and phonocardiogram, secretor specimen, Figure 4. Examinee flow chart. 21 nation. Special attention is paid to any entries which suggest a limitation on the youth's ability to perform any of the tests or procedures and to items which may require further followup in the course of the examination. It may be argued that a preexamination review of these forms would result in the physician's ex- amination not being quite the same for every ex- aminee. A blind-type design in which the physician did not see amedical history would produce some- what different results in some cases. It was felt, however, that the advantages of an examination procedure more nearly like that in clinical prac- tice outweighed these disadvantages. The phy- sician's examination includes an eye, ear, nose, and throat examination, check for goiter, mus- culoskeletal and neurological evaluation, cardio- vascular examination, grading of facial acne, as- sessement of sexual maturation, and an appraisal of nutrition. The nurse is present during the examination and in addition to drawing a sample of blood and obtaining blood pressure is also responsible for the completion of several procedures for the fe- male examinees. These are the completion of a questionnaire concerning the menses and collec- tion of a urine specimen for culture of bacteriuria. A "repeat'' urine collection is indicated if the cul- ture shows 100,000 organisms or more per cc. The examinee is rescheduled for two return visits as soon as possible and on consecutive days if convenient to the examinee. If the first repeat specimen shows less than 100,000 organisms per cc. the second visit may be cancelled. All cultures having 60,000 organisms or more per cc. are sent tothe University of Vir- ginia School of Medicine for organism identifica- tion and serotyping. The eye examination includes a careful, gen- eral inspection for evidence of abnormal condi- tions of the lids, conjunctivae, sclerae, pupils, and irides; a cover test for the presence of any tropia; an inspection of the conjugate gaze; and determi- nation of the focusing or dominant eye. For a variety of practical reasons a lengthy, highly structured, carefully standardized neuro- logical examination is not part of the physician's examination. Instead, after reviewing the total history, and testing a minimal number of reflexes, the physician performs as many neurological tests 22 as he feels are necessary either to satisfy him- self that no significant neurological abnormality exists or to delineate clearly the nature and ex- tent of any such abnormality, much as he would do in a clinical setting. Likewise, he uses a num- ber of simple prescribed procedures to obtain clues about possible musculoskeletal problems, such as loss of range of motionina joint or mus- cle weakness. These minimal screening tech- niques, coupled with the physician's judgment and skill in undertaking and interpreting any further tests, allows him to consider the child as normal in these respects or to obtain with reasonable accuracy and effort a coherent explanation of any neuromuscular or skeletal problem. The musculoskeletal examination consists of having the examinee puthis wrists, elbows, shoul- ders, hips, knees, and ankles through a full range of motions by a series of actions such as bending forward, abducting legs and arms, and squatting and touching toes. If he is unable to perform any one or more of these procedures, further exami- nation is given. For example, if he is unable to squat or fully abduct his legs, then the hip is in- vestigated by performing the Thomas test. Both tibial tuberosities are palpated for tenderness and swelling as definite evidence of past or present Osgood-Schlatter disease. Hand and foot domi- nance are determined by having the examinee state and demonstrate the preferred side. Prior to joining the field staff, the physician is given specific training in performing the ear, nose, and throat examination. This examination is of special interest because of the relevance of these findings to the audiometric data. The exam- ination consists of a general inspection of the external ear, routine otoscopic examination of the external auditory canals and tympanic mem- branes, pneumatic otoscopy, and examination of anterior nares, tonsils, and oral pharynx. The breast examination inmales is performed by inspection of both areolae and palpation of breast tissue for gynecomastia and tenderness. For females, maturation is graded and the breasts and axillae are palpated for masses. The genital examination for both sexes con- sists of evaluation of stage of maturation based on presence and distribution of the pubic hair, Fur- ther examination of males involves an inspection of the genitalia for circumcision and grade of ma- turation, the usual check for hernia, and palpation of the testicles for masses. The cardiovascular examination is a routine auscultation of the heart. If findings are present which are felt to be significant or even possibly significant, a tentative diagnosis is made. Because there is no recourse to trained cardiologists, all diagnoses based on cardiac auscultatory findings are considered "tentative' or likely but not defi- nite, Three blood pressure readings are taken— the first at the beginning of the physical examina- tion with the youth supine, the second with him supine after the examination, and the third im- mediately thereafter with the youth sitting on the edge of the examination table. The blood sample is taken to determine hema- tocrit and hemoglobin, levels of cholesterol, uric acid, serologic tests for syphilis, testosterone levels (in boys), protein-bound iodine, and to make extensive genotype determinations of the blood groups. For each youth, the parents are asked toname a physician (or clinic or other health facility) re- sponsible for the youth's medical care. This phy- sician later receives a summary of the youth's examination and many related tests, including a photographic copy of the chest X-ray. The exam- ining physician notes on this summary sheet any condition (such as serious intercurrent illness or new complication of known disease) of which he believes the physician may not be aware. Inthose few exceptional cases where it is warranted, the examining physician provides for prompt or im- mediate referral of an acutely ill youth to his phy- sician for indicated care, and may appropriately discuss the problem with the individual's physi- cian, More directly important to the survey is a parallel summary of findings which the examining physician makes for the survey records. Using his training and clinical judgment, the youth's medical history, his own examination, thehearing and vision tests, and the other data available to him from the other examination procedures, he decides whether or not the adolescent is basically healthy. Excluding from consideration mild, tran- sient problems such as minor cuts or bruises, fractured bones that healed without complication, and colds, he decides whether the youth before him has been and is developing satisfactorily and growing normally. Because of the small size of the survey sample, the number of cases of ab- normality traceable to any single given cardio- vascular, orthopedic, or other disease will be small. Nevertheless, data are available for ado- lescents who either are or are not normal and healthy in the opinion of well-trained pediatri- cians, In addition, he assigns specific medical explanations for those youths who have or have had significant disturbances in health or develop- ment, These impressions are useful in studying the prevalences of causes, or at least, groups of causes, of exceptions to the usual patterns of growth in this age group. Dental Examination The dental examiners derive their findings on a uniform basis by following, as closely as pos- sible, a written set of objective standards. The standards are guidelines which, in effect, narrow the range of examiner variability by eliminating many of the borderline or questionable conditions that are frequently a source of disagreement. To avoid other sources which might result in sys- tematic bias, the dentist does not dry or isolate teeth during the examination, remove oral debris and calculus, or probe any tooth surface that does not have an overt sign of decay. The dentist dictates to a trained recorder the condition of each tooth that is present. Teeth are classified as sound, filled, decayed, filled-defec- tive, or nonfunctional. Missing permanent teeth are also noted and each is classified under one of four groups: unerupted, carious extraction, ac- cidental loss, and orthodontic extraction. The ex- amination form also provides a means of record- ing the presence of artificial teeth, unshed primary teeth, and root remnants. The next step of the examination is an assess- ment of the periodontal structures and the status of oral hygiene. A periodontal index score is en- tered for each tooth. The score ranges from 0-8, depending on the absence or on the presence and extent of gingival inflammation and pocket forma- tion. An oral hygiene score, ranging from 0-6, is recorded for all or any of six predesignated teeth that are present. The score is an estimate of the amount of debris and the amount of calculus on selected surfaces. Fluoride and nonfluoride opac- 23 ities and fractures of the anterior are also re- corded, The dental examination ends with a detailed assessment of the occlusion and alignment of teeth, The relationship between upper and lower incisors is described by measuring the vertical and hori- zontal distance separating them. The occlusal re- lationship of posterior teeth is described by re- cording the anteroposterior position of the upper to the lower teeth and the number of upper teeth in crossbite. All displaced and rotated teeth are counted and recorded. An adjustable examining chair, a standard light source, and a mouth mirror and explorer are used in the examination of the teeth and gums, The examination is usually completed in less than 10 minutes. At the request of parents and with their authorization, the examining dentist fills out a brief report form which is sent to the youth's pri- vate dentist, A saliva sample is collected by the dentist to provide an estimate of the number of youths who secrete blood group antigens. It is collected on all examinees except those who have bleeding gums, Waxes or other substances to stimulate salivation are not used. Vision Examination The vision test battery is administered by the examining dentist, since this member of the ex- amining team has the requisite time available. The result is to have these procedures carried out by a professional person who, once the nec- essary special training has been given, is highly adept at administering the examination. Included in the vision examination are tests for color deficiency (Ishihara's screening test followed by Hardy-Rand-Rittler's test to establish fact, type, and degree of deficiency); tests for monocular and binocular visual acuity atdistance and near (Bausch and Lomb Master Orthorater with special Armed Forces plates supplemented by Landolt ring charts for illiterates); tests for distance and near lateral phoria; trial lens test for myopia for any examinee scoring less than 20/20 (Snellen notation) at distance; and lensometer readings for the glasses or contact lenses worn by the examinee. Color vision, visual acuity at dis- tance, thetrial lens test for myopia, and the lateral 24 phoria tests at distance and near are given both with and without glasses for the youths who nor- mally wear them. Administration of these tests usually requires about 10 minutes. Psychological Testing In line with the recommendations made by child psychologists from five universities and the National Institute of Mental Health, it was decided to continue the same test battery used for the chil- dren's examination, with slight modifications, to assess the mental health aspects of growth and development. This makes it possible to evaluate intellectual and emotional growth and development on a comparable basis throughout childhood and adolescence. After the pilot test, it was decided to use the following test battery in the survey. 1. Vocabulary subtest from the Wechsler Intelligence Scale for Children 2. Block design subtest from the Wechsler Scale 3. Human figure drawing administered as a modified Goodenough-Harris Drawing Test with drawings made of a person and a self-drawing of the examinee 4, Selected cards from the Thematic Apper- ception Test 5. Wide Range Achievement Test—theread- ing and arithmetic subtests of the 1963 version 6. A brief reading and writing test of literacy The psychometric battery is administered by psychologists who have been trained at least at the level of the master's degree and whohave had some experience in administering tests to adoles- cents. The time required to test a single youth is approximately 70 minutes. All but the literacy test forms, which were developed under special contract for the Health Examination Suvery,*? are available commercially, Except for the Thematic Apperception Test, the test forms include space for the required answers or entries. In the case of stories produced on the basis of the Thematic Apperception Test cards, the psychologist makes tape recordings which are later transcribed and made available for reading and evaluation. Procedures Performed by Technicians Four technicians conduct the following opera- tions of the examination: an audiometric test, X- ray of the chest, X-ray of the hand and wrist, measurement of height and weight, spirometry, electrocardiogram, test of grip strength, a series of body and skinfold measurements, and an exer- cise tolerance test. The audiometric testing is done in a special- ly constructed, acoustically treated room large enough for both the technician and the youth being examined. Because of space limitations it was also necessary to install another testing instrument— the Data Acquisition Unit (DAU)—in this room. The hearing tests are always done when the DAU is not in use. Special sound pressure level sur- veys are conducted to be sure that ambient noise in the test room is sufficiently attenuated to al- low for accurate testing. Each youth is tested at eight different fre- quencies with the 4,000 c.p.s. frequency repeated a second time. For each frequency the sound is presented separately to each ear in the randomized order prescribed on the recording form. Alterna- tion of presentation to each ear varies between examinees according to whether the examinee's sample number is odd or even. This is arranged so that for half of the youths the first ear tested is the right and for the other youths it is the left. The threshold recorded for each frequency is the lowest decibel level at which 50 percent or more of the responses are obtained, that is, two out of three or three out of five trials (fig. 5). Any con- dition such as earache, cold, or unusual behavior which may affect the test results is also recorded, Two X-ray films are taken. One is a 14x17 posterior-anterior film of the chest at a distance of 72 inches, and the other is a 8x10 film of the right hand and wrist for the determination of skel- etal age and bone density. All recommended pre- cautions to minimize radiation hazard are taken, including the use of a special ''no scatter'' cone, use of lead-rubber apron shields, and the wearing of radiation badges by the technicians. New radi- ation badges are provided at the beginning of each location. Periodic dosimetry field surveys are Audiometric testing. Figure ©. conducted by the Radiological Health Division of the U.S. Public Health Service, After the X-ray films are developed, they are reviewed by the physician before the examinees are released from the trailers so that inadequate films can be repeated. No formal readings of the X-rays are done atthe mobile examination center. However, the physician does screen the chest X- ray for abnormalities prior torecordinghis sum- mary of findings. Readings of the hand-wrist X- rays for assessment of bone age are being done by medical students with special training in this area, at Case Western Reserve University under the supervision of Dr. S. Idell Pyle. The results of a 12-lead electrocardiogram and spirogram are recorded on magnetic tape by use of a Data Acquisition Unit. Under terms of an agreement with the Medical Systems Development Laboratory, National Center for Health Services Research and Development, U.S. Public Health Service, the tapes are fowarded to their facilities for processing. For each examinee, the Health Examination Survey is provided with tabular print- outs and digital computer tapes of all basic data. For the electrocardiogram, this consists of the amplitudes and durations of various waves in each .of the 12 leads, as well as such data as QRS and T axes, rates, and so forth. Basic data for the spirogram will consist of measurements from three or four trials of maximal forced expiratory 25 Figure 6. Testing lung capacity. volume, the forced expiratory volumesatl1,2, and 3 seconds, the maximum expiratory flow rate, the maximum midexpiratory flow rate, and various peak flow rates (fig, 6), A test of grip strength is made using a dyna- mometer —three separate tests for each hand. The examinee is also questioned to determine his "handedness." A special self-balancing scale is used to re- cord the examinee's weight directly onthe record form. Following this, the examinee steps off the weight scale and stands on the platform of the height scale. The examinee is positioned with his back and heels against a vertical bar to which an adhesive strip with his examination number is fastened. He is asked to stand with feet together and head facing straight ahead in the Frankfort plane, After he has been positioned, a movable horizontal arm is adjusted to fit snugly on top of the examinee's head. The technician then presses a button attached to a camera mounted on the 26 Figure 7. Yeasuring standing height. movable arm which is focused on the scale and a pointer arrow indicating the height. A finished print is available shortly thereafter which be- comes a part of the examinee's record (fig. 7). In addition to the weight and standing height, 36 other body measurements are made. Seven- teen of these are similar to measurements taken in Cycle II. Various heights, breadths, and girths Figure 8. Taking body measurements. are all taken on the right side of the body with one exception, the medial calf skinfold. Skinfold thick- ness measurements are recorded to the nearest half millimeter while other measurements are recorded to the nearest millimeter. The measurements are made with one of the technicians performing the procedures and an- other acting as a recorder. A recorder is essen- tial for the recording of anthropometric data to insure the optimum accuracy in the collection of data and to assist in the correct positioning of the examinee, Since the recorder has had the same training as the examining technician, any errors noticed in the measurement procedures are called to the attention of the technician taking the meas- urements, As a measurement is read, it is re- ported to the recorder, who repeats the number, records it in the proper space, and gives the name of the next measurement (fig. 8). The exercise tolerance test is carried out by the use of a treadmill. The test consists of a 5- minute walk at a speed of 3.5miles per hour. The grade of incline during the first 2 minutes is zero, i.e., treadmill surface is level, after which it is raised to a 10-percent grade for the remaining 3 minutes, The result of the test isthe recording of the examinee's pulse rate. This is monitored and recorded by means of precordial leads going to a cardiotachometer which records both the electro- cardiogram and instantaneous pulse rate (fig. 9). Since reasonably constant ambient temperature and humidity are a very important part of this procedure, the room in which this test is admin- istered is kept between 70 and 74 degrees Fahr- enheit and between 50 and 60 percent relative humidity, The technicians perform a duplicate hemato- crit on each subject and are also responsible for the preparation and packaging of bloods sent to the independent laboratories for analysis. Bloods for the serologic tests for syphilis are sentto the Venereal Disease Research Laboratory, Com- municable Disease Center, Public Health Service. Each specimen is tested by the VDRL and the FTA-ABS methods. Determinations of total serum cholesterol, uric acid, and protein-bound iodine are made by the Lipid Standardization Laboratory of the Laboratory Branch, Communicable Disease Center, Public Health Service. Hemoglobin con- tent (MCHC) and blood typing are done by the Im- Figure ©. Exercise tolerance test. munogenetics Laboratory, Johns Hopkins Univer- sity. A specimen of plasma is frozen and stored for possible future determination of testosterone levels in the boys. SUPPLEMENTAL DATA Reasons for Collection In earlier sections of this report, reference has been made to the questionnaires obtained as supplemental data to the examination portion of the survey. Among these were the household ques- tionnaire administered by the Census interviewer, a youth medical history questionnaire completed by the parent and another by the youth, a health behavior questionnaire completed by the youth in the examination center, a marital history ques- tionnaire administered by the HER to the parents, and a questionnaire completed by the youth's school teacher or other school officials acquainted with the school record of the youth. A copy of the Zz birth certificate of each youth is requested from the appropriate State or city registrar's office. These supplemental data are collected for various purposes which can essentially be grouped into the following categories: 1. To provide a demographic frame against which the examination findings may be viewed. 2. To assist the physician inhis examination of the youth by alerting him to certain conditions necessitating further special examinations or to limitations requiring special handling in one or several of the procedures in the overall examination. 3. To facilitate subsequent survey opera- tions. (An example of this is information on grade and school of the youth.) 4, To relate health history, achievement, behavior, and other questionnaire data to specific findings of the examination. 5. To verify such information as date of birth or grade placement obtained from another source, Description of Supplemental Documents The household questionnaire, which was de- veloped jointly by members of the HES staff and Bureau of the Census personnel, is the basic source document of demographic data concerning the population sample; it also serves in the final stage of sample selection. The administration of this form by the Bureau of the Census interviewer has been described previously. In addition to ob- taining the age, race, and sex of all household members, a variety of other data is obtained from all households containing an eligible youth. These data include information on the school attended and the grade for each eligible youth, as well as information for each parent or guardianconcern- ing their education, country of birth, handedness, working status, and marital status. Information about the status of any other children from the present or previous marriage who are not pres- ently living in the household is asked of the par- ents only. The total family income and whether any language other than English is spoken in the 28 home are also determined. Parents or guardians are also asked three questions concerning theoc- currence of certain specified episodes such as death in the family, which might be regarded as potentially traumatic in the life of the youth. The Medical History of Youth questionnaire (appendix IB) completed by the parent or guardian, is primarily intended, as its name implies, to obtain data on the health history of the youth. In this respect, its value lies in several directions. It alerts the examining physician to certain con- ditions which may require him to administer fur- ther special examinations or to preclude the ex- aminee from participating in certain procedures of the overall examination, It also provides data which can be related to findings of the various procedures in the examination. For example, it provides information concerning injuries or oper- ations to the ear, or earaches and similar items which can be analyzed in relation to the results of the audiometric testing. The greater portion of the last page of the form is applicable to girls only and pertains to their menarche. The Health Habits and History questionnaire (appendix IC), left at the home to be completed by the youth, contains those items of health informa- tion which it is felt are best answered by the youth, For example, while the parent could surely answer whether the youth wears glasses or con- tact lenses, the youth would be better able to an- swer questions related to the necessity for glasses and, if glasses are worn but not all day, the oc- casions when he does use them. As in the case of the medical history completed by the parent, it also alerts the physician to certain conditions for further special examination procedures or to con- ditions which may preclude the examinee from participating in certain procedures, Several items are included which are also contained in the history questionnaire completed by the parent. These ""comparison'' type questions have been included where the agreement or disagreement between parent and youth is of interest. Examples of these are some medical history items, opinions of gen- eral health and physical growth, eating habits, and time since last saw a doctor and dentist, The Health Behavior questionnaire is com- pleted by the youth while in the examination center. The form is shown as appendix IE. Some of the questions on this form parallel those onthehealth history completed by the parent. Examples are items concerning educational goals, behavior standards, amount of parental involvementincer- tain decisions concerning activities of the youth, and the importance attached to certain medical conditions, Other questions concern smokinghab- its, difficulties with law officials, and the impor- tance of attention to certain dental conditions. Marital history information of the parents is obtained by the HER during her visit to the house- hold, The data collected is arecordof all marriage dates and the reasons for; and dates of termination in the case of broken or multiple marriages of either parent, Another piece of supplemental informationis that obtained from the school at which the youth is a student, This form, Supplemental Information From School, is shown as appendix ID. Mention has been made previously concerning the delivery, completion, and return of the form to the survey. A mail followup is made when the questionnaire is not received within a reasonable time. The school form serves to provide official information on the youth's grade placement, an item collected from the parent but subject to po- tential error. It collects other purely objective data such as date of birth, grades skipped or re- peated, absenteeism, and disciplinary problems, It obtains the teacher's evaluation of the youth's behavior, ability, and performance. Italsoidenti- fies any youths whose health problems or differ- ences (including mental ability) have come to the attention of the teachers or other school officials. Thus, for example, the youth who is knownto have a vision or hearing problem is identified. It also provides data on the availability and utilization of special resources needed. Most important, while the battery of psychometric tests provides valua- ble information on the youth's personality growth and development and on general levels of intel- lectual ability, the questionnaire will provide some comparative information which will give an indi- cation of the youth's actual accomplishment and performance in his real life situation. The final piece of supplemental data to be collected is the birth certificate of the youth. This document was also a part of the data collected in Cycle II and therefore will already be available for some of the Cycle III examinees. Data ob- tained on the household questionnaire and the med- ical history completed by the parent provide the necessary information to make the request from the appropriate State or city registrar's office. Permission to acquire this information is obtained during the course of the HER interview. A copy of the birth certificate is desired for several rea- sons, It is important, particularly in connection with the scoring of psychological tests and for the analysis of all the growth and development data, to have the exact and correct age for each child, It is also felt that the mother's age at the birth of the child could be obtained more accurately from this document than from reconstruction from the age reported in the household interview along with the child's age. Finally, the birth certificate pro- vides some information relating to the child at birth (birth weight, congenital conditions noted at that point, and complications of delivery) which can be related to some of the findings of the sur- vey examination. QUALITY CONTROL The efforts of the quality control program extend to all phases of the operation—from the beginning of the Census interview until all col- lected data has been coded, edited, and placz=d on magnetic tape for computer use. The goal of the program is to assure that the national estimates of the various characteristics collected by the survey represent data of the highest attainable accuracy and precision within the limitation im- posed by reasonable procedures and costs. In the Health Examination Survey, as in all sample surveys, there are two sources of error to be considered—sampling error and nonsam- pling or measurement error, Sampling error, that is, error due to making measurements ona sample rather than on the entire population, can be quan- tified and is the concern of all statisticians in sample survey design and in analysis. During the data-collection phase, problems due to this type of error are minimal, The nonsampling error is of constant concern during the data-collection phase and considerable attention, time, and effort of the HES personnel are devoted toward minimiz- ing and measuring this type of error. One type of nonsampling error which occurs in voluntary surveys such as the HES is the bias introduced by nonresponse. The amount of bias 29 introduced by nonresponse generally, but notnec- essarily, varies with the amount of nonresponse. Even if the sample is perfectly representative of the population, bias will result if the nonrespond- ents differ from the respondents with respect to the characteristics being measured. The response rate of a survey such as the HES is, therefore, very critical. Fortunately, the low proportion of sample persons not examined in the various HES programs to date has not produced any serious effects on the validity of the data. Response rates for Cycles I and II were 86.5 and 96.0 percent, respectively, Approximately 90.0 percent of the sample youths in Cyclelll will be examined. These high response rates may be attributed to various methodological studies,*® to advance planning and publicity, to much diligent work by the Health Examination Representatives, and to proper han- dling of examinees by the entire staff, Another type of nonsampling error which is of great concern in the quality control program is the measurement error which inevitably occurs during the examination procedure. Its importance is easily recognized when one considers that, in the present cycle, each sample youth has arepre- sentative sample weight of approximately 3,000. Therefore, any blemish on the survey findings for a particular youth is greatly enlarged in the final analysis of the larger universe. Not only is it im- portant to control and minimize this error but it is also equally important to measure, wherever possible, the amount of error. In the Health Examination Survey several pro- cedures are relied upon to accomplish these ob- jectives. Prior to the collection of data it was nec- essary to define precisely what is to be measured and to obtain instruction as to how the measure- ment should be performed. Advisors, both from within the staff of the HES and from outside sources, were instrumental in constructing the necessary definitions and instructions. Intensive specialized training is given to each examination staff member in the specific procedures per- formed by them in the survey. The special ad- visors within the HES provide training in their respective areas with additional training in other areas obtained from various outside sources. Although precise definitions and good initial training are necessary, they are generally not sufficient in a lengthy survey such as the HES, 30 The time factor creates a problem that does not occur when data are gathered in a shortperiod of time. It is important to be consistent throughout the entire survey. In order to accomplish this, detailed written instructions are provided on all aspects of the examination, forms are structured, and retraining is provided. The latter may range from a few minutes for a single item up to several days for an entire area such as body measure- ments. In further efforts to attack measurement er- ror, mechanical equipment is employed wherever feasible to obtain a "hard document." These are obtained through the use of such devices as tape recorders, automatic recording of weight, photo- graphs of height, X-rays, and the recording of spirometry and electrocardiograms on magnetic tape. As such, the reading and interpretation of these records can be done independently more than once. The use of instruments for measuring as well as for recording introduces another source of possible variation; thus, systematic calibra- tion is necessary. All instruments are calibrated at the beginning of each stand and also periodi- cally throughout the stand, some before each ex- amination. In some instances, audiometers for example, resources are not available in the ex- amining center and machines must be sent away for calibration. Other instruments also receive peri- odic maintenance and service through special con- tract arrangements with the manufacturers. Environment is also an important factor in achieving valid and standardized data. Good light- ing, heating, and air conditioning are essential. For example, it is very important to be able to standardize temperature and humidity in the room where the exercise tolerance test is given. Simi- larly, it is essential that the room in which the hearing test is given be soundproof. The subject being examined can also intro- duce error into the measurement. If the examinee fails to stand up straight for a height measure- ment, is uncooperative during the psychological examination, or doesnot understand the directions given for the audiometry test—to give only a few examples—error will occur. Itis, therefore, very important that staff members be aware of such possibilities and see that the examinee fully un- derstands what he is to do and thathis fullest co- operation is obtained. Despite all precautions, there is a degree of inherent variable measurement error that cannot be eliminated. Another objective of the quality control program, therefore, is the determination of the extent of this error. In the HES this is de- termined by replicate measurements. Replicate data are obtained basically in two ways: by re- evaluation or rereading a hard document, or by reproduction of an actual measurement. Although hard documents such as the X-ray or the weight and height measurements are reevaluated, the replicate program is primarily concerned with reproducing actual measurements in a replicate examination. During the actual operation of the survey, the primary use of replicate data is in indicating areas where retraining or reevaluation of procedures is needed. When the reports of findings of the survey are published, data from the replicates will be used to apprise the reader of the extent to which the data may be affected by measurement error and to call his attention to this problem. There are several sources of replicate data in the HES, The single most important source is the full-scale replicate examination where apre- viously examined youth is returned to the exami- nation center for a second examination, complete except for the X-rays, blood sample, and urine culture. The number of youths replicated at a lo- cation varies between 12 and 18 depending on the number of examination slots available. These are randomly drawn by segment from those examined during the first 2 weeks of the examinations. Scheduling and other necessary arrangements do not permit sufficient time to select youths for replicates who are examined at a later date. In performing these replicates, the examining staff does not have access to any original records ex- cept the medical histories. The examiners have been instructed to use the same techniques as they use in a regular examination andnottotry to col- lect any "better'' data than they wouldina routine examination. No efforts are made toassigna par- ticular youth to a particular examiner but as al- ways, the examiner is identified: thus, both intra- and inter-observer variability can be studied. Although for various reasons it has not been pos- sible to do full-scale replicate examinations at all stands, the total for the first 31 stands of this cycle is 231, with an estimated number of 325 for all 40 stands. Aside from the full-scale replicates, repli- cate data is obtained from several specific areas of the examination. One of these is in body meas- urements. Replicate body measurements are per- formed on a systematic basis on ''dry runs'' day at the beginning of each location. "Dry runs' day is a half day set aside for the examination of four youths not in the sample to check all equipment at the beginning of each stand. The examination content is the same as that for the sample youths and the records of findings are sent to their phy- sician and dentist. During the course of the ex- aminations, two of thedry-run examinees are used for replicate body measurements. Each technician performs measurements on one of the examinees, thereby providing two sets of replicate data. The pairing of technicians alternates from location to location so that after every three locations, each technician will have been paired with the other three. Technicians are not allowed to observe the other technician's procedures or review results of the measurements of the sample youths on whom they are to take replicate measurements, After all replicates have been performed, the supervisory technician compares the two sets of measurements for each youth. If the differences for any meas- urement are greater than the allowable tolerances, these measurements are repeated on the youth by both technicians inthe presence of the supervisory technician who observes their-procedures andre- solves any technical variations. Any changes in a technician's measurements resulting from this procedure are recorded. However, inthe analysis of this replicate data, the original measurements are used since they provide the best estimates of the intertechnician measurement error. Replicate body measurements are also made to obtain es- timates of intratechnician error. This is accom- plished by having each technician repeat his own measurements on one examinee during the course of a stand. Although blood is not drawn during replicate examinations, replicate determinations are made for the blood chemistry tests. Replicate readings of hematocrit for all examinees are made in the examining center by using split samples. Repli- cate determinations on the other blood chemistries performed by independent laboratories are ob- tained by drawing additional blood samples on 30 regular examinees at each location, splitting each sample, and assigning sample numbers so that the 31 two cannot be related by the laboratory. In addi- tion, each laboratory also has its own quality con- trol procedures which include the useof replicate determinations. Several measures are taken to assure com- pleteness and consistency in the recording proc- ess, All questionnaires are reviewed for omis- sions and inconsistencies. With the exception of the Health Behavior questionnaire which is com- pleted in the examining center, all are reviewed by personnel in the field management office. If errors are noted, correct information is obtained by phone or from the examinee when he comes in for the examination. Errors in recording body measurements and results of the dental examina- tion are reduced by having a second personact as a recorder. In addition, all data gathered in the examining center are reviewed by the clerical assistant before the examinees leave. There are numerous quality control proce- dures involved in the psychological testing area. Tests are exchanged daily by the psychologists and checked for errors in counting items, com- puting age, recording scaled scores on the WISC, and recording grade levels on the WRAT. Once each week, six WISC tests, chosen at random from those given by each psychologist during the week, are exchanged and rescored. Scoring disagree- ments are marked and discussed. If, throughdis- cussion, the original scorer decides thathis scor- ing was in error, the score is changed accordingly. All human figure drawings, which are scored by Dr. James L. McCary, University of Houston, are independently scored by two persons. Each week an audit tape on one complete testing session is recorded. This tape serves as a quality control device not only for the psychological advisor at headquarters, but also for the field psychologist who needs to observe his own performance at regular intervals, A list of any unusual occur- rences which may affect the validity of the data is also maintained. REFERENCES INational Center for Health Statistics: Origin, program, and operation of the U.S. National Health Survey. Vital and tlealth Statistics. PHS Pub. No. 1000-Series 1-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1963. 2National Center for ilealth 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. 3U.8. National Health Survey: A study of special purpose medical-history techniques. Health Statistics. PHS Pub. No. 584-D1. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1960. 40.8. National Health Survey: Attitudes toward coopera- tion in a health examination survey. Health Statistics. PHS Pub. No. 584-D6. Public Health Service. Washington. U.S. Government Printing Office, July 1961. 50.8. National Health Survey: Evaluation of a single- visit cardiovascular examination. Health Statistics. PHS Pub. No. 584-D7. Public Health Service. Washington. U.S. Govern- ment Printing Office, Dec. 1961. ONational Center for Health Statistics: Comparison of two visions=testing devices. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 1. Public Ilealth Service. Washing- ton. U.S. Government Printing Office, June 1963. 32 "National Center for Health Statistics: The one-hour oral glucose tolerance test. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 3. Public Health Service. Washington . U.S: Government Printing Office, July 1963. 8National Center for Health Statistics: Cooperation in health examination surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 9. Public Health Service. Wash- ington. U.S. Government Printing Office, July 1965. INational Center for Health Statistics: Replication, an approach to the analysis of data from complex surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 14. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1966. 10National Center for Health Statistics: Three views of hypertension and heart disease. Vital and Health Statistics. PiiS Pub. No. 1000-Series 2-No. 22. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1967. UNational Center for Health Statistics: Factors related to response in a health examination survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 36. Public Health Service. Washington. U.S. Governr.ent Printing Office. In pub- cation. 12National Center for Health Statistics: Cycle I of the Health Examination Survey, sample and response, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1964. 13National Center for Health Statistics: Glucose tolerance of adults, United States, 1960-1962. Vital and Health Statis- tics. PHS Pub. No. 1000-Series 11-No. 2. Public Health Serv- ice. Washington. U.S. Government Printing Office, May 1964. 14National Center for Health Statistics: Binocular visual acuity of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 3. Public Health Service. Washington. U.S. Government Printing Office, June 1964. 15National Center for Health Statistics: Blood pressure of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 4. Pub- lic ilealth Service. Washington. U.S. Government Printing Office, June 1964. 16National Center for Health Statistics: Blood pressure of adults by race and area, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 5. Public Health Service. Washington. U.S. Government Printing Office, July 1964. 1TNational Center for Health Statistics: Heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 6. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1964. 18National Center for Health Statistics: Selected dental findings in adults by age, race, and sex, United States, 1960- 1962. Vital and Health Statistics. PIS Pub. No. 1000-Series 11-No. 7. Public Health Service. Washington. U.S. Government Printing Of fice, Feb. 1965. 19National Center for Health Statistics: Weight, height, and selected body dimensions of adults, United States, 1960- 1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11.No. 8. Public Health Service. Washington. U.S. Government Printing Office, June 1965. 20N ational Center for Health Statistics: Findings on the serologic test for syphilis in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 9. Public Health Service. Washington. U.S. Government Print- ing Office, June 1965. 2INational Center for Health Statistics: Coronary heart disease in adults. United States, 1960-1962. Vital and Health Statistics. PIS Pub. No. 1000-Series 11-No. 10. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1965. 22National Center for Health Statistics: Hearing levels of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PIS Pub. No. 1000-Series 11-No. 11. Pub- lic Health Service. Washington. U.S. Government Printing Office, Oct. 1965. 23National Center for Health Statistics. Periodontal dis- case in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 1i-No. 12. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1965. 24National Center for Health Statistics: Hypertension and hypertensive heart disease in adults, United States, 1960- 1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 13. Public Health Service. Washington. U.S. Jovern- ment Printing Office, May 1966. 25National Center for Health Statistics: Weight by height and age of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 14. Public Health Service. Washington. U.S. Government Printing Office, May 1966. 26National Center for Health Statistics: Prevalence of os- teoarthritis in adults by age, sex, race, and geographic area, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 15. Public Health Service. Wash- ington. U.S. Government Printing Office, June 1966. 2TNational Center for Health Statistics: Oral hygiene in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 16. Public Health Service. Washington. U.S. Government Printing Office, June 1966. 28National Center for Health Statistics: Rheumatoid arth- ritis in adults, United States, 1960-1962. Viial and Health Statistics. PHS Pub. No. 1000-Series 11-No. 17. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 29National Center for Health Statistics: Blood glucose levels in adults, United States. 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 18. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 30National Center for Health Statistics: Age at meno- pause. United States, 1960-1962. Vital and Health Statistics. PiIS Pub. No. 1000-Series 11-No. 19. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1966. 31National Center for Health Statistics: Osteoarthritis in adults by selected demographic characteristics, United States, 1960-1962. Vital and Health Statistics. PAS Pub. No. 1000- Series 11-No. 20. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 32National Center for Health Statistics: Childbearing and diabetes mellitus, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 21. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 33National Center for Health Statistics: Serum cholesterol levels of adults, United States, 1960-1962. Vital and Heallh Statistics. PHS Pub. No. 1000-Series 11-No. 22. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1967. 34N ational Center for Health Statistics: Decayed, missing. and filled teeth in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 23. Pub- lic Health Service. Washington. U.S. Government Printing Office, Feb. 1967. 35National Center for Health Statistics: Mean blood hema- tocrit of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 24. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1967. 36National Center for Health Statistics: Binocular visual acuity of acults by region and selected demographic charac- teristics. United States, 1960-1962. Viial and ilealth Statis- tics, PHS Pub. No. 1000-Series 11-No. 25, Public {Iealth Service. Washington. U.S. Government Printing Office, June 1967. 33 3TNational Center for Health Statistics: Hearing levels of adults, by race, region, and area of residence, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 26. Public Health “Service. Washington. U.S. Government Printing Office, Sept. 1967. 38 ational Center for Health Statistics: Total loss of teeth in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 27. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1967. 39National Center for Health Statistics: ilistory and exam- ination findings related to visual acuity among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub, No. 1000-Series 11-No. 28. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1968. 40N ational Center for Health Statistics: Osteoarthritis and body measurements. Vital and Health Statistics. PHS Pub. No. 1000-Series 11:No. 29. Public iiealth Service, ‘Washington. U.S. Government Printing Office, Apr. 1968. 41National Center for Health Statistics: Monocular-bin- ocular visual acuity of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11i-No. 30. Public iIealth Service. Washington. U.S. Government Printing Office, Apr. 1968. 42National Center for Health Statistics: dearing levels of adults, by education, income, and occupation, United States, 1960-1962. Vital and Health Statistics. PIIS Pub. No. 1000- Series 11-No. 31. Public Health Service. Washington. U.S. Government Printing Office, May 1968. 43National Center for Health Statistics: Hearing status and ear examination: findings among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 32. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1968. 44National Center for Health Statistics: Plan, operation, and response results of a program of children’s examinations. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 5. Public Health Service. Washington. U.S. Government Print- ing Office, Oct. 1967. 45National Center for Health Statistics: Evaluation of psychological measures used in the health examination sur- vey of children ages 6-11. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 15. Public Health Service. Wash- ington. U.S. Government Printing Office, Mar. 1966. 48N ational Center for Health Statistics: Calibration of two bicycle ergometers used by the health examination survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 21. Public Health Service. Washington. U.S. Government Print ing Office, Feb. 1967. 4TNational Center for Health Statistics: A study of the achievement test used in the health examination surveys of persons aged 6-17 years. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 24. Public ilealth Service. Wash- ington. U.S. Government Printing Office, June 1967. 48National Center for Health Statistics: Orthodontic treat ment priority index. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 25. Public ilealth Service. Washington. U.S. Government Printing Office, Dec. 1967. 49National Center for Health Statistics: Development of the brief test of literacy. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 27. Public Health Service. Wash- ington. U.S. Government Printing Office, Mar. 1968. 000 34 APPENDIX IA leased to others for any purpose. 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 re- BUDGET BUREAU NO. 68-R1700 APPROVAL EXPIRES JULY 31, 1970 FORM NHS-HES-3 U.S. DEPARTMENT OF COMMERCE (5-16-66) BU REAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE HEALTH EXAMINATION SURVEY 1. Questionnaire of —_____ Questionnaires 2a. Address or description of location (Number and street, city, State) 4. PSU number 3. Identifica- tion code 5. Segment number 6. Serial number | NTA Segment, enter: If this questionnaire is for an ‘EXTRA’ unit in a B or Serial number 2b. Mailing address if not shown in 2a OR [] Same as shown in 2a Item number of original by which Sample Unit found If in NTA Segment, also enter for FIRST unit listed on property Segment List Sheet No. Line No. 2c. Name of special dwelling place 1 Code | [] Housing unit 7. Type of living quarters — Check one box [] Other unit Ask Items 8 and 9 only if “‘Rural’’ box is marked L For questions 10 — 12, ask only the questions checked: : [JDO NOT ASK QUESTIONS 10-12. Go to question 13. [] Rural 1 [] All other — Skip to Item 10 8. Do you own or rent this place? [J] Own [J Rent [J Rent free Ask 9a Ask 9b Ask 9a 9a. If Own or Rent free, ask: Does this place have 10 or more acres? b. If Rent, ask: Does the place you rent have 10 or 110. [T] Are there any occupied or vacant living quarters BESIDES YOUR OWN in this building? [Yes -$ Fill Table X for each quarters NOT listed. [INo more acres? [Yes No . During the past 12 d. During the past 12 n 11. Are there on Oo on this floor [Yes S$ L Fill Table X for each quarters NOT listed. y occupied or vacant living quarters BESIDES YOUR OWN [JNe months did sales of crops, livestock, and other farm products : from the place amount to $250 or more? months did sales of 2 crops, livestock, and other farm products from the place amount to $50 or more? 4] No 3JYes S[INo 12. [] Is there any other building on this property for people to live in — either occupied or vacant? []Yes—S§ L oe Fill Table X for each quarters NOT listed. [CINo 2] Yes [ | [ | | | [ [ | [ | 13. What is the telephone number here? ————p Telephone No. OR [] No telephone 14. INTERVIEWER: If eligible youth in household enter youth’s name, Cycle III segment, serial, and column numbers on Medical History Form. In addition to the information you have already given me, | would like to leave this form to be filled out about — —. representative of the Public Health Service will come by to pick up the form in a week or so. What would be the best time of day for her 10 COMET memset Column No.(s) of EY(s) for whom Msigion) History Form(s) were eft: Column No. and relationship of erson with whom form(s) were eft: Best time to call: 15. RECORD OF CALLS AT HOUSEHOLD Item 1 Com. 2 Com. 3 Com. 4 Com. 5 Com Entire h hold Date Time 16. REASON FOR NON-INTERVIEW TYPE | A B c Z (Partial interview) 21 [] Refusal —Describe in footnotes 31 [] Vacant --Non-seasonal 41 [] Demolished 42 [] In sample by mistake Interview not obtained for b. Who supplied this information? (Name and address) ¢. Are there any EY’s in this Type A household? [] Yes [Neo [] DK (Explain on page 4) ersons| EY’s 22 [| No one at home — repeated G 32] Vacant --seasonal calls 3 0 to 33 [] Usual residence elsewhere | 43 [] Eliminated in sub-sample | Cols. —— 23 [] Temporarily absent 17 [34 [] Other — Specify 44 [] Other — Specify because: 24 [] Other — Specify | 17a. For ““final’’ Type A noninterviews enter names and approximate ages of household members. 18. Signature of interviewer Name Age Name Age 1. 4. 19. Code 2 Is. 3. ls. WASHINGTON USE ONLY SY’s 35 36 la. What is the name of the head of this household? Enteg name in first column. b. What are the names of all other persons who live here? List all persons who live here. C [J] DIFFERENT household [J No Cycle II questionnaire [C] Noninte rview in Cycle II Go to item E c. | have listed (read names). ls there anyone else staying here now such as friends, Last name relatives, or roomers? .......... iin vo a wee os soap Lo } VBE [1 No d. Have | missed anyone who USUALLY | here but is now away from home? ws «[]Yeas* [J No Kimono sues tot wea age seve mee] e. Do any of the people in this household have a home anywhere else? ..............[ ]Yes* [1 No First name *Apply household membership rules 2. How is -- related to -- (head of household)? Relationship Enter relationship to head, for example: wife, daughter, stepson, grandson, mother-in-law, partner, roomers wife, etc. HEAD | [] White 2] Negro 3. Race — Mark one box for each person 3 [] Other 4. Sex — Mark one box for each person | [[] Male 2[] Female Age [] Under 5. How old were you on your last birthday? 1 year For each youth age 11— 18 listed on the questionnaire, ask: NOTICE: (Check birth date and age against Month Day Year 6. What is the month, day, and year of --"s birth? * AGE VERIFICATION TABLE card HES-3b After completing questions 1—6 for all persons, check a i against Ey II [J SAME household — Mark 458 Jou ih ganh Repeat a Sans oF en ITEM | questionnaire and mark appropriate box. —— Sous eR ember. ther go to questionnaire [7] New household member questions on Page 1. Mark ““EY”’ box for each eligible youth (age 12 —~ 17) listed on the questionnaire. If no EY, ask coverage ITEM EY Questions 7 — 16 must be asked only of parent(s) or guardian(s) of EY, If no parent or guardian is at home, a RNa EY arrange to call back when they will be -. ASK FOR 00 [] None PARENTS Elem... 12345678 (GUARDIANS) 2High..;1 234 OF EY AND 7a. What is the highest grade -- attended in school? .... viii iii iinet enas 3 College. 12345+ FOR EY i te es 7 bi Did »« Sinviah this grode (YEN. corr sev svn ars vrt vs rennsss srs ves ervasversass] § [Yes 2[ No eam ve si nt wr ry Name and location Ask only for EY: c. What is the name and location of the school-=goes to? vc. vivitar If “Not in school’’ ask: 0 [] Not in school d. What is the reason --isnotgoingto school? « «cc tii t itt ten tint rns arn anannee Enter reason above, ASK FOR 80. Was «« born in the United $102e8? « «cov everrrenrcrrrennverssonserenrsrnrsaren | []Yes-US 2[ No | PARENTS If No," ask: Foreign country OR GUARDIANS b. Where was -- born? Enter the name of the COUNTY. vv vv a ss vot snes asso sos st sesnnons OF EY | [] Right 2 [7] Left 9. Is -- primarily right-handed, primarily left-handed, or both? ..... iii nnnraan 3] Both 10a. What was -- doing most of the past THREE months — [1] Working [] Keeping (for males): working or doing something else? * + «++ cv vv esven Somethi 1 house (for females): keeping house, working or doing something else? +... [J Something else If “Doing something else,"” ask: b. What was -- doing? Enter reply verbatim and ask 10C +. ve coves sss asso sronsssnansns mr a If “Keeping house’* OR ‘‘Doing something else,’’ ask: i c. Did -- work at a job or business at any time during the past THREE months? +... 00s ene von [Yes [J No If “Working” in 10a OR “Yes” in 10c, ask: CIFell [JPere } de Did oe» work full-time or part-time? «uv eve vs srs rs sree v in Cos npr crass eres sien time time 11a. Are you now married, widowed, divorced, or separated? + vv vives vss ans ares saan | (Married 3 [] Divorced 2 [Widowed 4 Separated If “Married,” ask: J C8 b. Have you (your husband) been married more than once? . ovo ev vivir itn nnsnnvorsoanas TT Yes TNe | ASK FOR [1 No parent in household — Go to question 13 . PARENTS Name of child ONLY 12a. Besides (read names of children entered in question 1) have you and your husband (a) (wife) ever had any other children (in this marriage or in a previous marriage)? [J Yes [JNo If “Yes,” ask: b. What are their names? Enter names in column (a). c. How old is --? What is his date of birth? Enter age AND date of birth. If deceased enter ‘‘deceased’’ in column (c), date of birth in column (d), and month and year of death in column (e). d. Where does he (she) live now? Enter present whereabouts Last name Last name Last name Last name Last name [First name [Firstname |Firstname ||First name | First name = Relationship Relationship Relationship Relationship Relationship | [JWhite 2[_] Negro | [] White 2 |Negro |! []White 2[ Negro | | [_]White 2[|Negro| | [White 2 []Negro 3 [7] Other 3 [] Other 3 [] Other 3 [] Other 3 [] Other | [] Male 2] Female | I[]Male 2] Female| | [] Male 2[JFemale | | [Male 2[JFemale| | [Male 2 [Female Age [J Under Age [] Under Age [J Under Age [_] Under Age [] Under 1 year 1 year 1 year 1 year 1 year Month Day Year Month Day Year Month Day ay Month foe Year Month Day Year "] Same as column on Cycle questionnaire [7] New household member [] Same as column on Cycle questionnaire [1 New household member [7] Same as column on Cycle II questionnaire [] New household member Same as column - on Cycle II questionnaire [] New household member [] Same as column on Cycle II questionnaire [] New household member I[JEY 20NaEY |1EY 20Nat EY] 1 [J EY 20 Not EY| 1 [EY 2] Not EY| I (J EY 2] Not EY 00 [7] None 00 [J None 00] None 00 [| None 00 [] None 1Elem...12345678|1Elem...12345678]IElem...12345678|1Elem...12345678| Elem 12345678 2Wigh..+.123¢ 28igh... 1224 2High...1234 2High:..1284 2High...1234 3 College. 1 2 3 4 5+ 3 College. 1 2 3 4 5+ 3 College. 1 2 3 4 5+ 3 College. 1 2 3 4 5+ 3 College. 1 2 3 4 5+ IT] Yes 2[ No ICIYes 207Ne I[JYes 2[]No ICIYes 20Ne IC] Yes 2[ Ne Name and location 0 [] Not in school Enter reason above. Name and location 0 [] Not in school Enter reason above. Name and location 0 [J Not in school Enter reason above. Name and location 0 [| Not in school Enter reason above. Name and location 0 [Not in school Enter reason above. Foreign country Foreign country 1 [J] Yes-U.S. 2[]No Foreign country 1 []Yes-U.S. 2[]No Foreign country I []Yes-U.S. 2[]No Foreign country [1] Something else [] Something else [] Something else IC JRight 2[JLeft |I[JRight ~~ 2[JLeft | I [Right 20 Left | 1 []Right 2 Left | 1 [J Right 207] Left 3] Both 3] Both 3] Both 3[] Both 3 [] Both 3 Working [JKeeping| [Working [Keeping] [] Working [Keeping [] Working [_]Keeping| [_] Working [|] Keeping house house house house house [] Something else [] Something else 2 [Widowed 4 [_ Separated 2[]Widowed 4 [Separated 2 []Widowed 4 [Separated {7 Fall- ClPar- | [J Full- J Pan- | CJ Full- [] Pan CC Pan J Full- CC] Pan- time time time time time time time time time | [Married 3 [Divorced] | [ Married 3 [ Divorced] | [ Married 3 [Divorced] 1[ Married 3[]Divorced| | [Married 3[]Divorced 2 [JWidowed 4[_] Separated 2 [Widowed 4[ "| Separated Relationship to both or either parent — Specify (b) Date of birth Month Day Year Present whereabouts (e) 37 13a. Since (name of oldest EY) was born has anyone in the family been in a hospital, an institution, or any similar place for MORE THAN A THREE MONTH PERIOD? +o ooo vv ve enn soe ennnnennnennns [J Yes [J No — Go to 13b If “Yes” ask: Who was this? Enter name and relationship to parent of EY in cols. (b) and (c). When was this? Enter calendar year in col. (d). What is the name of the place he was in? (Enter in col. (e). b. During that period, has anyone in the fcmily been unable to work or carry on his usual activities for MORE THAN A SIX MONTH PERIOD because of ill-health? . ......vuvvuiunennennansensan. [Yes [J No — Go to 13¢ If ““Yes’’ ask: Who was this? Enter name and relationship to parent of EY in cols. (b) and (c). When was this? Enter calendar year in col. (d). c. Since -- was born has any relative of yours died WHILE LIVING IN YOUR HOUSEHOLD? .......... [J Yes [JNo — Go to 14 If “Yes” ask: Who was this? Enter name and relationship to parent of EY in cols. (b) and (c). When was this? Enter calendar year in col. (d). Relationshit fo FILL FOR 13a ONLY : 1; Question No. Name parent of Fy | Cal. Year(s) Name of the place (a) (b) (c) (d) (e) 14a. Is any language other than English spoken here in your home? ......... | [J Yes 2] No If “Yes,” ask: b. What language(s)? Language(s) spoken [1 SAME household — Complete question 15 [J DIFFERENT household [1 No Cycle II questionnaire Skip to question 16 [] Noninterview in Cycle II Fill from item C, page 2: ——————————p 15. If no one has left household, check: [] All household members are the same — Go to question 16 For each person who was listed originally as a household member but is not listed on this questionnaire, enter his name and column number (from Cycle II questionnaire) and ask: In the last survey, we had-- listed as living here in this household, where is he (she) now? Col. No. on Name Cycle II quest. Present whereabouts (If deceased, enter ‘‘deceased’’) 16. Which of these income groups represents your total combined family income for the past 12 months, that is, | Group your's, your--'s, etc? Show Income Flash Card HES-3b. Include income from all sources, such as wages, | salaries, rents from property, Social Security or retirement benefits, help from relatives, and so forth, — 2 ’ | Complete front page of questionnaire de Footnotes and comments: Include here any information which might be useful to the PHS representative when she calls to pick up the Medical History Form. TABLE X — LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS Ais th USE OF CHARACTERISTICS CLASSIFICATION IF HU IN B SEGMENT, ASK re these = (Specify location) Occupied All Quarters Not a [Fill In what year S [quarters for more Location of unit |Do the occu- [Do these (Specify local Sepa- |separate were these (If before July 1960) Z |than one group pants of these|tion) quarters have: |rate Jagstion, (Specify location) 5 © of people? Specify loca- unit naire an quarters 2 = Peon (Examples: rs Direct ac- | A kitchen (Add interview |created? What was the name of e 2 Yes No Basement, live and eat |cess from |or cooking] J (If 1959 or 1960, the household head 2] 2 2nd floor, etc.) with any other| the outside| equipment gents also specify “F»» | of these quarters on § [(Fillone group of or through | for exclu- | 70 Et Toros mer or April 1, 1960? Y [tine for people? a common | sive use? | o, _ «Lif last half) S |each hall? tion- Hu [Other Bros) Yes No |[Yes|No |Yes| No [naire unit D] 2 (3a) (3b) (4) (5a) | (5b) |(6a) |(6b) | (7a) |(7TD)] (8) (92) | (9b) (10) (an 1 2 APPENDIX |B CONFIDENTIAL — 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). DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE ME NATIONAL HEALTH SURVEY DICAL HISTORY OF YOUTH Parent's Questionnaire Sample number NAME OF CHILD (Last, First, Middle) SEGMENT SERIAL COL. NO. NOTE: Please answer the questions by checking the correct boxes or by filling in the blanks, as required. If a question is unclear leave the answer blank and draw a line around the ques- tion. A representative of the Public Health Service will collect your filled in questionnaire in a few days and she will help you answer the unclear questions. Thank you for your cooperation. 1. SEX 2. AGE 10mte 2 Oremate 3. DATE OF BIRTH (Month, Day, Year) 4. PLACE OF BIRTH (City or Town, State) 5. Was this youth born in a hospital giving birth to this youth? IF YES: What was wrong? ® 1 ] Yes 2 OJ No 3 OJ Don’t know 6. Did you ( the mother) have unusual medical problems or complications while pregnant or 1 [J] Yes 2 J No 3 Don’t know Was anythirz wrong with him or h fF YES: a. What was it? er at birth? 1 Cd] Yes 2 Od No 3 J Don’t know b. What did the doctor say cause d this? 8. Was there anything wrong with this child as a baby (that is, before he or she was one 1 [J Yes 2 J No 3 1 Don’t know year old)? IF YES: a. What was the matter? b. Did you see a doctor about it? 1 l] Yes 2 O No 3 {iil Don’t know FOR PUBLIC HEALTH SERVICE USE ONLY 1 [J Mother This form completed by: 2 O paher 3 [J Other (Specify) Interviewer Date reviewed 9. Has there been any serious health problem since he or she was one year old? Ll ves : Ovo IF YES: What and when? 3 OJ Don’t know 10. Is there anything about hisor her health that worries you now? 1 Cd ves 2 Ono IF YES: What is it? 11. How would you describe his or her present health? 1 5 Poor 2 N Fair IF POOR OR FAIR: What is 3 Ol Good 4 OJ Very Good the matter? 5 OJ Excellent 39 12. Does he or she now use any medicine regularly (not counting vitamins)? 1 . Yes 2 OJ No 3 O Don’t know IF YES: a. What is the name of the medicine? 2 0 Don’t know b. What is it for? 2 O Don’t know c. Did a doctor say he or she should use it? 1 [yes 2 O No 3 OJ Don’t know d. How long has he or she been using it? 13. Has he or she ever broken any bones? 1 O Yes 2 0 No 3 OJ Don’t know 14. Has he or she ever had any other serious injuries or accident? 1 ¥ Yes x [J No (IF.NO, SKIP TO QUESTION 15) IF YES: a. How many? 0 One Od Two OJ Three O Four or more b. As a result of any accident did he or she have to stay in a hospital (overnight or longer)? 1 OJ Yes 2 C1 No c, What lasting handicaps or damages, if any, did the accident(s) produce? 15. Has he or she ever been unconscious? 1 . Yes 2 [ne 3 O Don’t know IF YES: For how long? 1 I One hour or less 3 O A day or more 2 O More than an hour 4 O Don’t know but less than a day 16. Which of the following operations or surgery has he or she had? (Check all that apply.) 1 [J ronsits and/or adenoids taken out 2 a Appendix taken out 3 Od Hernia (Rupture) 4 other; what? 9 O None 17. Has he or she ever been in a hospital (ovemight or longer)? 1 Yes 2 0 No (IF NO, SKIP TO QUESTION 18) IF YES: a. What was the longest time he or she ever spent in a hospital? 1 O A night to a week 2 O Over one week but less than six months 3 O Six months or longer - b. How old was he or she at that time? _ years c. Why was he or she there? d. Did an adult family member spend the night with him (her) in the hospital most of the time? + [J ves 2 No 40 18. Has he or she ever had (CHECK YES OR NO IN EVERY LINE), a. Measles [0 Yes 2 J No b. Mumps 1 O Yes 2 O No ¢. Chickenpox 1 Yes 2 J No d. Whooping cough 1 O Yes 2 OJ No e. Scarlet fever 1 OJ Yes 2 OJ No f. Asthma 1 OJ Yes 2 OJ No g. Hay fever 1 OJ Yes 7 0 No h. Other allergies 1 J Yes 2 OJ No i. Kidney trouble 1 J Yes 2 O No emperor Lvs. o[ k. Fit, convulsion, or seizure 1 O Yes 2 OJ No I. Pneumonia 1 ] Yes 2 O No 19, Below is a list of other diseases. Please read through it carefully and check the YES box if he or she ever had any of the following: (a) Diabetes or sugar diabetes (f) Diphtheria (b) Rheumatic fever (g) Tuberculosis (T.B.) (c) Polio (Infantile Paralysis) (h) Cerebral palsy (d) Epilepsy (i) Meningitis or sleeping sickness (e) Chorea or St. Vitus dance 1 . Yes 2 J None of these IF YES: Which? 20. What ic the most serious illness or disease he or she has ever had? a. How old was he or she when it started? years b, What did the doctor say about it? The doctor said it was: 1 J a mild case 4 O I don’t remember what he said 2 J a moderate case 5 O No doctor saw the child 3 0 a severe (critical) case ¢, Did the illness (disease) leave any lasting effects? [J ves Ono 3] Hard to say IF YES: What were or are they? 21. Has he or she wet the bed during the past year? 1 0 Yes 2 O No 3 Od Don’t know 22. Does he or she wear glasses or contact lenses? 1 O Yes, glasses 3 OJ Yes, contact lenses 2 0 No, don’t wear either IF NO: Do you think he or she needs glasses? 1 O Yes 2 O No 3) Don’t know 41 42 23. 24. 25. 21. 29. 30. 31. 32. 33. 34. Has he or she ever had eye trouble (except what is corrected by glasses or contact lenses)? 1 Yes 2 O No IF YES: What was it? Has he or she ever had an eye operation? 1 Yes 2 7 No IF YES: What was it for? Have his (her) ears ever been damaged or injured in any way? 1 5 Yes 2 O No IF YES: In what way? . Have his (her) ear drums aver been opened or lanced? [ves = we IF YES: a. How many times: 1 J Once 2 J More than once b. In which ear? 1 O Left 2 OJ Right 3 OJ Both 4 OJ I don’t remember Has he or she ever had any other kind of ear operation? 1 CJ Yes 2 OJ No IF YES: a. What was it for? b. Which ear? . Has he or she ever had a running ear or any discharge from the ears (except waz in the ears)? 1 » Yes X J No IF YES: a. How often? 1 0 Once 2 OJ More than once b. From which ear? 1 OJ Left 2 OJ Right 3 OJ Both 4 J 1 don’t remember In the past year has he or she had an earache? 2) ves 2» (Io Does he or she have any difficulty hearing? 1 a Yes 2 ol No Has he or she had any other ear trouble? tL ves 2 No IF YES: What? Does he or she have any speech defect (like stuttering, stammering, lisping, etc.)? 1 O Yes 2 OJ No Does he or she have a limp or other trouble walking? 1 OJ Yes 2 ll No Is there anything that prevents complete use of his (her) legs? tL] ves tL) % IF YES: What is it? 35. Is there anything that prevents complete use of his (her) arms? : Elves 2 [No IF YES: What is it? 36. Is he or she now prevented for reasons of health from taking part in hard exercise or play? : 0 Yes x [I No (IF NO, GO ON TO QUESTION 37) IF YES: a. What are the reasons? b. Did the doctor advise this? LT 2 No 37. Was he or she ever prevented for reasons of health from taking part in hard exercise or play? 1 O Yes 2 Od No 3 Od Don’t know 38. Have his (her) teeth been straightened or have bands been put on them? 1 J Yes 2 Y No IF NO: a. Do you think they need straightening? 1 i Yes 2 OJ] No b. Has a dentist said they need straightening? 1 0 Yes 2 OJ No 39. At the present time is he or she: 1 J Underweight 2 OJ About the right weight 3 J Overweight 40. As far as physical growth is concerned, is he or she coming along: 1 ] Too slowly 2 OJ At about the right rate 3 OJ Too fast 41. As far as mental development is concerned, is he or she coming along: 1 Too slowly 2 J At about the right rate 3 [Joo fast 42. How often has he or she stayed overnight at a friend’s house? 1 OJ Never 2 OJ Only once or twice 3 Od Quite a few times HERE ARE SOME QUESTIONS ABOUT SCHOOL: 43. Did this youth go to nursery school? 1 OJ Yes 2 a No 44. Did he or she go to kindergarten? 1 5 Yes 2 0 No IF YES: Was it: 1 J Compulsory 2 OJ Voluntary 45. At what age did he or she start first grade? OJ Five or younger J Six O Seven or older 43 44 46. What was his or her reaction to school during the first few weeks of 1st grade? 1 OJ Was quite happy 2 OJ Was a little upset 3 OJ Was quite upset 4 J Was so upset, he or she got sick 5 OJ I don’t remember or don’t know 47. In general, how easily does he or she make friends? 1 UJ Easily 2 O Has a little trouble 3 Od Has a lot of trouble 48. How many of his or her friends do you know well? 1 Od Most of them 3 O Half or less 3 a Almost none 49. How much trouble was he or she to bring up? 1 OJ None 2 a Just. a little + [J some «OA 5 O Don’t know 50. Some people are calm, others are nervous (tense, high-strung). Which describes him or her best? 1 0 Not nervous at all 2 OJ Somewhat nervous 3 a Very nervous 51. Has this youth ever been to a mental hospital or guidance clinic? 1 a Yes, within past year 3 Uno 2 O Yes, but not within past year 4 Cl Don’t know 52. Has he (she) ever seen a psychiatrist, or a psychologist, or have you talked to one about him (her)? 1 Od Yes, within past year 3 [I No 2 a Yes, but not within past year 4 [J pont know HERE ARE THREE QUESTIONS ABOUT EATING HABITS: 53. Would you say he or she eats: 1 Od Too much 2 Od About the right amount 3 [J Too little 54. How fussy an eater is he (she): 1 OJ Not fussy at all 2 OJ A little fussy 3 O Very fussy 55. On a usual day (that is, school or work day), how many meals does he or she eat with adult family members? 1 Od Two or more 2 a Only one 3 Od None 56. Who makes most of the decisions on the following: (Check one in each row). a. Choosing his/her clothes b. How to spend his/her money c. Which friends to go out with d. How late he/she can stay out 57. Does he or she get an allowance? (So much money per week, for example.) Ll ves Ll IF YES: Who decides how much? IF NO: Does he or she earn money from work? 2 OO ves 5s [No 58. Looking ahead, what would you like him or her to do about school? (Check one only.) 1 J Quit school as soon as possible 2 Od Finish high school 3 OJ Get some college or other training after high school 4 J Finish college and get a college degree 5 O Finish college and take further training (medical, law, or other professional school, etc.) 59. What do you think will happen, as far as school goes? (Check one only.) 1 O Quit school as soon as possible 2 Od Finish high school 3 a Get some college or other training after high school 4 [3 Finish college and get a college degree 5 O Finish college and take further training (medical, law, or other professional school, etc.) 45 46 60. How important do you think it is for a young person to have each of the qualities or characteristics listed below? (Put one check mark in each row.) Extremely Slightly Important | Important | Important | Unimportant 1) 3) 4) a. To be neat and clean b. To be able to defend oneself c. To have self-control Qu . To be happy @ . To obey one’s parents - To be dependable . To be considerate of others > . To face life’s problems calmly . To obey the law —- . To be ambitious . To know how to keep in good health 61. If he or she had any of the following conditions, what would you want to do? (Place one check mark in each row.) If my child had this condition I would: Definitely want to get in touch with a doctor 1 Probably want to get in touch with a doctor 2) Not want to get in touch with a doctor (3) © . Stomach ache . Sore throat Hurt all over Stiff neck or back . Headache ~~ . Vomit (throw up) Li . Loss of appetite = . Overtiredness — . Pain in chest — . Lump in stomach or abdomen . Blood in urine or bowel movement — . Nervousness 62. 63. 64. 65. 66. 67. 68. 69. Some people when they are sick talk as if they are sicker than they really are, that is, they exaggerate a little. How often does he or she do this when he is sick? 1 O Pretty often 3 OJ Almost never 2 a Not very often ; 4 ad Never As far as you are concerned, how often is it all right for him (her) to exaggerate a little bit when he (she) is sick? 1 0 Pretty often 3 O Almost never 2 O Not very often 4 O Never When did a doctor last see him (her) for a check-up (routine examination)? 1 7 In the last year 4 O Never 2 OJ One-two years ago 5 CC Don’t remember or don’t know 3 OJ Over two years ago When did a doctor last see him (her) for treatment? 1 OJ In the last year 4 J Never 2 a One-two years ago 5 OJ Don’t remember or don’t know 3 OJ Over two years ago What is the name and address of the doctor he/she goes to (or clinic if there is no regular family doctor)? Name Street 2 Od None City and State When did he (she) last see a dentist for a check-up (routine examination)? 1 O In the last year 4 OC Never 2 J One-two years ago 5 0 Don’t remember or don’t know 3 0 Over two years ago When did he (she) last see a dentist for treatment? 1 O In the last year 4 O Never 2 O One-two years ago 3 a Don’t remember or don’t know 3 a Over two years ago What is the name and address of the dentist or dental clinic he/she goes to? Name O None Street City and State 47 48 FOR GIRLS ONLY 70. Have her monthly periods (menstruation) started? 1 yl Yes 2 [JNo (IF NO, OMIT QUESTIONS BELOW) IF YES: a, Had she been told about them before hers began? b. How old was she when they started? C. e, 1 J Yes 2 J No 3 J Don’t know Years Months Does she have pain or discomfort? 1 [izes 2 5 No 3 Don’t know (IF NO OR DON’T KNOW, OMIT EST CF QUESTION. If there is pain or discomfort, B YFSTIONS 1 O Very often 2 O Occasionally 1 J Mild 2 J Moderate 3 O Severe At that time, does she frequently: (Check all that apply) 1 Take medicine 4 O Stay home from school 2 O Go to the sick room or nurse 5 O None of these 3 Stay in bed Has she talked to a doctor about painful menstruation? 1 | Yes 2 Od No 3 O Don’t know O00 APPENDIX IC CONFIDENTIAL — 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). DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY Sample No. HEALTH HABITS AND HISTORY - Youth Name (Last, First, Middle) SEGMENT [SERIAL |COL. NO, INSTRUCTIONS: On the following pages you will find a set of questions dealing with your health. Since every person is different, there are no “standard” answers to the questions; just answer them as fully and honestly as you can. Your answers will be kept confidential. Do your best to pick the most likely answer from among the choices given. Only if you really don’t know the answer check “Don’t know.” WHEN YOU HAVE COMPLETED THE QUESTIONNAIRE, PLEASE MAIL IT BACK TO THE SURVEY IN THE ENVELOPE WE LEFT WITH YOU ~-THERE IS NO POSTAGE NECESSARY IF YOU USE OUR ENVELOPE. 1. SEX 2. AGE 3. DATE OF BIRTH (Month, Day, Year) 1 J Male 2 [J Female 4. How would you describe your present health? 1 Poor 2 Fair 3 OJ Good 4 OJ Very good 5 OJ Excellent IF POOR OR FAIR: What is wrong? 5. Do you have any problems you might like to talk over with a doctor? 1 Yes 2 (Ino IF YES: What are they? 6. Do you now use any medicine regularly, not counting-vitarins? 1 vs 2 ] No 3 OJ Don’t know IF YES: a. What is its name? 0 Don’t know b. What is it for? 2 O Don’t know c. Did a doctor say you should use it? 1 a Yes 2 Ono 3 J Don’t know d. How long have you been using it? 7. Have you ever broken any bones? 1 Yes 2 O No 3 O Don’t know IF YES: a. How many times? (Several bones broken at the same time count as once.) i OJ Once 2 J Twice 3 OJ Three times or more b, How did it happen? 49 50 8. Have you ever had any other injuries or accidents? I] yes 2d No IF YES: What happened? 9. As a result of an accident, a blow, a fall, or other such cause, have you ever been unconscious? 1 OJ Yes 2 No 5 O Don’t know 10. Have you ever stayed in a hospital (overnight or longer)? 1 Yes, just once 3 No 2 Yes, more than once 4 OJ Don’t know IF YES: What was the longest time you ever spent in a hospital, and for what reason? How long: Reason 11. What was the most serious illness or disease you had in your life? a. How old were you when it started?__________ years b. Did you have to stay in a hospital overnight or longer? 1 Od Yes 2 OJ No 3 OJ Don’t remember c. What lasting effects did it leave? HERE ARE A FEW QUESTIONS ABOUT YOUR EYES AND EARS. 12. Do you ever wear glasses or contact lenses? 1 Yes, glasses 3 No 2 Yes, contact lenses IF YES: IF NO: a. With your glasses (or contact lenses) can you see as well as most people? 1 J Yes 2 [No 1 [Yes Ovo (GO ON TO QUESTION 13) Do you think you need glasses? b. Do you think you need new glasses? 1 a Yes 2 O No c. When do you wear them? 1 [J Not all day 2 OJ All day IF NOT ALL DAY: d. When? (Check all that apply) 1 0 For seeing at a distance 2 OJ For reading 3 [J For Tv « other (speci) 13. Is there anything wrong with your eyes (except what is corrected by your glasses or contact lenses)? 1 Yes 2 OJ No IF YES: What? 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. Do you have any difficulty hearing? 1 | Yes 2 0 No Were your ears ever damaged or injured in any way? 1 I Yes 2 O No 3 OJ Don’t know a. IF YES: a. In what way and when? b. Which ear (s)? In the past year, how often did you have earaches? 1 O Not at all (I can’t remember any) 2 O Not very often (about once a month or less) 3 0 Quite often (more than once a month) Have you ever had any other kind of trouble with your ears? 1 Yes 2 OJ No IF YES: What was it? Do you think your teeth need straightening? 1 a Yes 2 0 No 3 a Don’t know Do you have any difficulty talking or speaking (like stuttering or lisping)? 1 a Yes 2 0 No Is there anything wrong with the way you walk? 1 i Yes 2 a No IF YES: What? Is there anything that prevents your complete use of your legs? 1 L] Yes 2 OJ No IF YES: What? Is there anything that prevents your complete use of your arms? 1 Yes 2 a No IF YES: What? Have you ever been prevented for reasons of health from taking part in hard (physical) work, exercise, or games? 1 R Yes X a No IF YES: a. Why? b. Did a doctor advise this? 1 OJ Yes 2 ig No 3 OJ Don’t know c. Are you now forbidden to do some of these things? 10 Yes 2 [No 51 24. 25. 26. 21. 28. 29. 30. At the present time, do you think you are: 1 OJ Underweight 2 0 About the right weight 3 O Overweight Would you say that you appear to be: 1 Od Thinner than most persons of your age 2 O About the same as most persons your age 3 Od Heavier than most persons of your age At this time, would you like to be: 1 a Thinner than you are 2 a About the same weight as you are 3 a Heavier than you are At this time, would you like to be: 1 OJ Less tall than you are 2 a About as tall as you are 3 a Taller wan you are In the last year or two, have you had any backaches? 1 OJ Yes, quite often 2 Od Yes, occasionally 3 O No Do you sleep alone in your own room? 1 [J Yes 0 IF NO: No Who else sleeps in the room? Od Brother(s) 3 O Fatner 2 O Sister(s) 4 a Mother 5 OJ Other person(s) How often do you have trouble getting to sleep or staying asleep? 3 O Never 1 O Very often 2 OJ Only from time to time 31. How often do you have bad dreams or nightmares? 32. 52 3 a Never As far as you know, have you walked in your sleep in the last year or so? 10 ves > ro 1 Od Quite frequently 2 OJ Only from time to time 33. Do you have acne (pimples or blackheads)? [ves tL Ne IF YES: a. At what age did it start?___years b. Do you use any treatment for it? 1 OJ Yes 2 OJ No c. Have you seen a doctor about it? 1 OJ Yes 2 OJ No d. How much does it bother or worry you? 1 OJ Quite a lot 2 I Some but not too much 3 J Very little 4 OJ Not at all 1 [J Yes, once X OJ No 2 Yes, more than once IF YES: 34. Have you ever been away from your family (home) for at least two months? a. Where did you stay? (Check all that apply) 1 OJ Camp 4 Od With a relative 2 a Boarding school 3 OJ Hospital b. How old were you when this happened for the first time? 1 Yes IF YES: 3 OJ Elsewhere years 35. Are you going to school? (If you are now on vacation and will return to school, check “Yes.”’) a. During the school year, how many hours do you work? (not counting homework for school) 1 a I don’t work (GO TO QUESTION 36). 2 O 1-4 hours a week 3 OJ 5-9 hours a week 4 Od 10-20 hours a week 5 J Over 20 hours a week 6 O I work, but can’t tell how many hours b. What kinds of work do you do? c. Do you get paid for this work? aa. Do you have a job? 7 J Yes 8 OJ No, but I am looking for one. 9 Ovo, and I am not looking for one. (AFTER THIS ANSWER, GO TO QUESTION 37). 53 54 36. 37. 38. 39. 40. 41. 42. 43. Do you work during vacation time? 1 i Yes, full-time 2 J Yes, part-time 3 OJ No Do you get an allowance from your family (so much money per week, for example)? 1 Yes x i No IF YES: (IF. NO, GO ON TO QUESTION 38) a. Who decides the amount you are to get? [J Father 2 OJ Mother 3 0 Both parents 4 J Someone else (Specify) b. Who do you think should decide about it? 1 OJ Father 2 OJ Mother 3 0 Both parents 4 somes else (Specify) c. Are there duties or chores you have to perform to get this allowance? 1 OJ Yes 2 OJ No d. Is your allowance ever held back as a punishment? 1 OJ Yes 2 OJ No Now about your eating habits, do you think you eat 1 0 Too much 2 OJ About the right amount 3 J Too little When did you last see a doctor for a checkup (routine examination)? 1 0 In the last year 4 UJ Never 2 J One-two years ago 5 0 I don’t remember 3 Od Over two years ago When did you last see a doctor for treatment? 1 O] In the last year 4 J Never 2 OJ One-two years ago sJ I don’t remember 3 OJ Over two years ago When did you last see a dentist for a checkup (routine examination)? 1 O In the last year 4 O Never 2 OJ One-two years ago 5 Ch don’t remember 3 OJ Over two years ago When did you last see a dentist for treatment? 1 OJ In the last year 4 ed Never 2 fe One-two years ago 5 OJ I don’t remember 3 OJ Over two years ago ONE LAST QUESTION About how much time would you guess you spend in the usual day (enter number of hours or fraction of hours, or zero, as appropriate)? a. Watching television b. Listening to radio c. Reading newspapers, comics, magazines d. Reading books (except comic books) APPENDIX ID All information which would permit identification of an individual or of an establishment 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 the provisions of 42 CFR Part I. PHS-4733-5 (PAGE 1) Form Approved: REV. 9-66 DEPARTMENT OF Budget Bureau No. 68-R1700 # HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS HEALTH EXAMINATION SURVEY SUPPLEMENT AL INFORMATION FROM SCHOOL The student whose name appears below is one of the sample of students being studied in the Health Examination Survey. This student’s parent or guardian has given us written authorization to obtain information from the school. Please com- plete this form on the basis of school records and/or information the student’s teacher or other school official may have. A pre-addressed envelope, requiring no postage, is furnished for your convenience in returning this form. AME OF YOUTH (Last) (Firat) (Middle) SAMPLE NUMBER “OME ADDRESS ‘For identification) . BIRTH DATE (Month) (Day) (Year 2. WHAT IS THE PRESENT GRADE PLACEMENT OF THIS STUDENT? grade. 3. HAVE ANY GRADES BEEN SKIPPED OR DOUBLE PROMOTIONS BEEN GIVEN? 2 O NO 3 O DON'T KNOW v [J ves—p IF YES, Which grades were skipped? 4. HAVE ANY GRADES BEEN REPEATED FOR ANY REASON? 2 [no 3 [J pont know + OJ ves—3 IF YES, Which grades were rep d? 5. IF GRADES WERE REPEATED, WHAT WAS THE MAIN REASON? (Check only one) 1 EXCESSIVE ABSENTEEISM (excused) 2 TRUANCY 3 MOVED INTO MORE DIFFICULT SCHOOL SYSTEM a SOCIAL IMMATURITY 5 ACADEMIC FAILURE go oOonD 6 OTHER (explain) o HAS THIS STUDENT BEEN ABSENT FROM SCHOOL AN UNUSUAL NO. OF DAYS DURING THE MOST RECENTLY COMPLETED SCHOOL YEAR? 2 OO no 3 [J oon’ know v OO YES——3- IF YES, WHAT IS THE MAIN REASON FOR THE ABSENCES? (Check only one) 1+ [0 Student's illness 2 [J Illness in student’s family 3 [J Due to work (either away from home or at home for reasons other than family illness) a 0 Truancy s [J Other (explain) 55 7. HOW FREQUENTLY IS ANY SPECIFIC DISCIPLINARY ACTION REQUIRED FOR THIS STUDENT? 1 [0 FrequenTLY 2 [J occasionaLLy 3 Onever 4 0 NO BASIS FOR JUDGING WHICH OF THE ABOVE FITS THIS STUDENT 8. ARE SPECIAL RESOURCES NEEDED OR CURRENTLY BEING USED FOR THIS STUDENT? 2 [Jno (SKIP TO QUESTION 9) + [J ves—= IF YES, complete the following only for those special resources needed or currently being used by this youth: RESOURCE NEEDED REASON FOR NON-USE (Check one) (Check primary reason) SPECIAL RESOURCE BEING nor [AVAILABLE over. | stupenT | PARENTS OTHER (spect) USED AVAILABLE] NOT USED CROWDED OBJECTS OBJECT pecify, a. For the gifted b. For the mentally retarded c. For "slow learners’’ not classed as mentally retarded d. For emotionally disturbed e. For orthopedically handi- capped f. Special facilities for the **hatd of hearing’’ 8. Special facilities for the visually handicapped h. Speech therapy i. Remedial reading j- English for students from non-english speaking environments k. Remedial training in special subject area(s) 1. Other resources needed (specify) 9. IN TERMS OF ADJUSTMENT, WHICH OF THE FOLLOWING BEST DESCRIBES THIS STUDENT? + [J seems weLL AbsusTED. 2 [[] SEEMS SOMEWHAT MALADJUSTED. 3 [J seems seriouSLY MALADJUSTED. 4 NO BASIS FOR JUDGING WHICH OF THE ABOVE FITS THIS STUDENT. 10. IN TERMS OF INTELLECTUAL ABILITY, WHICH OF THE FOLLOWING BEST DESCRIBES THIS STUDENT? 1+ [J asove averace 2 [J averace 3 [J seLow averace 4 0 DON'T KNOW STUDENT WELL ENOUGH TO JUDGE. 11. IN TERMS OF ACADEMIC ACHIEVEMENT, IS THIS STUDENT: 1 Od IN THE UPPER THIRD OF HIS CLASS 2 0 IN THE MIDDLE THIRD OF HIS CLASS 3 0 IN THE LOWER THIRD OF HIS CLASS a Ooonr KNOW yp IF DON'T KNOW, Specify reason 12, IN TERMS OF POPULARITY WITH OTHER STUDENTS, IS THIS STUDENT: 1+ [J asove averace in POPULARITY 2 [OO asouT AVERAGE IN POPULARITY 3 [J seLoW AVERAGE IN POPULARITY a [J pont know 13. HOW LONG HAVE YOU KNOWN THIS STUDENT? 1 [J Less THAN ONE SEMESTER 2 [J MORE THAN ONE SEMESTER BUT LESS THAN ONE YEAR 3 [J MORE THAN ONE YEAR BUT LESS THAN TWO YEARS. 4 [J MORE THAN Two YEARS SIGNATURE OF PERSON COMPLETING THIS FORM OFFICIAL TITLE DATE FORM COMPLETED 000 57 APPENDIX IE CONFIDENTIAL — 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 dis- closed or released to others for any other purposes (22 FR 1687). DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL HEALTH SURVEY Sample No HEALTH BEHAVIOR NAME OF YOUTH (Last, First, Middle) S. AGE EX [OMale [Female INSTRUCTIONS: On the following pages you will find a set of questions dealing with your health behavior. Since every person is different, there are no ‘‘standard’’ answers to the questions; just answer them as fully and honestly as you can. Your answers will be kept confidential. Do your best to pick the most likely answer from among the choices given. Only if you really don’t know the answer check ‘‘Don’t know.”’ 1. Looking ahead, what would you like to do about school? (Check one only) 1 OJ Quit school as soon as possible C4 J Finish college and get a college degree 2 J Finish high school 5 OJ Finish college and take further training (medical, law or other professional 3 a Get some college or other training school, etc.) ‘ after high school 2. What do you think will happen about school? (CHECK ONE ONLY) 1 a Quit school as soon as possible 2 a Finish high school 3 a Get some college or other training after high school 4 J Finish college and get a college degree 5 Od Finish college and take further training (medical, law or other professional school, etc.) 3. Have you ever had a date? (That is, a boy and girl going out together, whether or not anyone else was along.) } 1 Yes x J No IF YES: How old were you when you first had a date? years 58 Who makes most of the decisions on the following: (Check one in each row.) I~ TTR IR IR o re) = > = £ 3 = © E 7 s 8 g 3 s =z « 5 = LE) = S Q « S @ 2 Ss 3 o =~ Ey oo 2 | & = 2 EE) 2) 5 [ 2 Q 5 oS 3 5 &, = ay o @ |[@ | 6 |@ [B® [6 | DO |® | O a. Choosing your clothes b. How to spend your money c. Which friends to go out with d. How late you can stay out 5. How many times have you run away from home? (That means, leaving or staying away on purpose, knowing you would be missed, intending to stay away from home, at least for some 3 OJ Never time.) 1 Once 2 More than once IF ONCE OR MORE: How old were you then? years How many times have you had anything to do with police, sheriff, or juvenile officers for 4 OJ Never ‘6. something you did or they thought you did? 3 | More than twice 1 [once 2 [vice IF ONCE OR MORE: 3 J Don’t know a. What was wrong? b. Were you arrested? 1 UJ Yes 2 J No c. In what way were you punished? 2 UJ Not at all 7. How old were you when you smoked for the first'time? Years OJ Never tried (SKIP TO QUESTION 10) Years 8. How old were you when you began smoking regularly? J Never have smoked regularly 9. About howmany cigarettes do you smoke per day? 1 OJ I don’t smoke at all 2 OJ I don’t smoke cigarettes (but I smoke a pipe or cigars) 3 a Less than 1/2 pack 4 OJ 1/2 pack but less than 1 pack s[] 1 pack but less than 2 packs 6 a 2 packs or more 59 60 10. At what hour do you usually go to bed when the next day is a school or work day? 11. Do you ever feel tense, nervous, or fidgety? 1 Yes, often 2 0 Yes, sometimes 3 Od Yes, but rarely 4 Ol Never 12. How important do you think it is for a young person to have each of the qualities or characteristics listed below? (Put one check-mark in each row.) Extremely Slightly Important Important Important Unimportant (1) 2) 3) 4) a. To be neat and clean b..To be able to defend oneself c. To have self-control d, To be happy e. To obey one’s parents f. To be dependable g. To be considerate of others = . To face life’s problems calmly . To obey the law j. To be ambitious k. To know how to keep in good health 1 co . If you had any of the following conditions, would you want a doctor iv know about it? (Includes your seeing him or a telephone call about t.) (Place one checkmark in each row. ) If I had this condition, I would: Definitely want to Probably want to Not want to see a doctor see a doctor see a doctor (1) 2 (3) . Stomach ache » b. Sore throat . Hurt all over o ao. . Stiff neck or back e. Headache fad . Vomit (throw up) g. Loss of appetite h. Overtiredness i, Pain in chest . Lump in stomach or abdomen k. Blood in urine or bowel movement — . Nervousness 14. (Place one checkmark in each row.) 1f you had any of the following conditicus, would you want to see a dentist about it? If I had this condition, I would: Definitely want to see a dentist (1 Probably want to see a dentist (2) Not want to see a dentist 3) . Crooked teeth © b. Sore gums c. Bad breath d. A toothache e. Sores in the mouth ™ . Stains on the teeth that would not brush off g . Hole or cavity in a tooth— even though it did not hurt 000 61 62 TIME IN APPENDIX IF Confidentiality has been assured the individual as set forth in 22 FR 1687 DEPARTMENT OF HEALTH EXAMINATION SURVEY—III CONTROL RECORD HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL CENTER FOR WASHINGTON, D.C. HEALTH STATISTICS 20201 Form Approved. Budget Bureau No. 63-1170 PROCEDURE URINE SPECIMEN AUDIOMETRY ECG and PHONO. SPIROMETER STAFF PROCEDURE, OR PART OF OVERALL PROCEDURE NOT DONE REASON FOR NON-COMPLETION [1 mate TREADMILL [J special Notes SECRETOR TEST BODY MEASUREMENTS and GRIP STRENGTH [J Negative FMO Check: HEIGHT-WEIGHT X-RAYS (CHEST, HAND) TIME OUT DENTAL EXAMINATION VISION PHYSICIAN'S EXAMINATION VENIPUNCTURE NURSE'S QUESTIONNAIRE PSYCHOLOGICAL PROCEDURES BEHAVIORAL QUESTIONNAIRE EXAMINATION DATE (mo., day, yr.) BIRTH DATE (mo., day, yr.) AGE SEX TEMPERATURE 1[Om2[]r (Initial) SEQUENCE NUMBER SAMPLE NUMBER HEALTH EXAMINATION SURVEY —III AUDIOMETRY AUDIOMETER NO. (6-9) EXAMINER (10-11) USE THIS SECTION WHEN CARD USE THIS SECTION WHEN SAMPLE NO. IS EVEN COL. NOS. SAMPLE NO. IS ODD cps cps ~~ —_— = fein ee — t _ ee ' — 2000: R CT] L (28-31) 2000: R 1] Lr ¥ ¥ — re v Y ~~ —_ lp KE DO ' pe CONDITIONS AFFECTING TEST RESULTS: (Check) (48) O [] None CONDITIONS AFFECTING TEST RESULTS 1 [] Cold at present 4 [[] Cold within past week 5 [] Earache within past week 7 [] Other* 2 [[] €or discharge 3 [] Equipment defective* ~~ 6 [] Behavior* * Specify frequency (cps.) if only certain one(s) affected, and describe: SAMPLE NO. (1-5) 64 HEALTH EXAMINATION SURVEY—IH BODY MEASUREMENTS Measurements in cm. unless otherwise specified. EXAMINER RECORDER CARD CARD cot. STANDING cot. SEATED NO. NO. 8-11 | CERVICALE HEIGHT ° 8-10 | BIZYGOMATIC BREADTH . 12-15 | ACROMIAL HEIGHT ° 11-13 | BIGONIAL BREADTH ° 16-19 | RADIAL HEIGHT ° 14-16 | ELBOW—ELBOW BREADTH . 20-23 | STYLION HEIGHT . 17-19 | SEAT BREADTH . 24-27 | ILIAC CREST HEIGHT . 20-22| FOOT LENGTH . 28-31 | TROCHANTER HEIGHT . $1ANBING 32-35 | TIBIAL HEIGHT _ ___ @-_—_ |23-25| BIACROMIAL BREADTH a SEATED > 26-28 | BICRISTAL BREADTH —— 36-39 | SITTING HEIGHT (Erect) _ @— |29-31| BITROCHANTERIC BREADTH i di sets 40-42 | THIGH CLEARANCE e— |32-3a| UPPER ARM GIRTH Si 43-45 | SPHYRION HEIGHT __ __ e___ |35-37| FOREARM GIRTH is yaa 46-48 | FOOT BREADTH __ e- |38-41] cHEsT GRTH i sine RE Od Longer 42-45 | WAIST GIRTH ass ns sss a Ist TOE RELATIVE 0 TO 2nd TOE Susie 46-49 | HIP GIRTH CJ some 50-52 | ANKLE BREADTH °— 50-52| CALF GIRTH ° 53-55 | KNEE BREADTH © -—__ |33-55| TRICEPS SKINFOLD (mm.) er seit 56-58 | ELBOW BREADTH ° 56-58 | SUBSCAPULAR SKINFOLD (mm.) ° 59-61 LATERAL 59-61 | WRIST BREADTH ° CHEST SKINFOLD (mm.) ° [J tonger 62-64 | SUPRA-ILIAC SKINFOLD (mm.) 62 | 2nd (Index) FINGER Seay. uti fins RELATIVE TO [7] shorter 41h (Ring) FINGER 65-68| WEIGHT (Ibs.) . O Same 63-65 | MEDIAL CALF SKINFOLD (mm.) = 66-69 | STANDING HEIGHT II MEASUREMENTS NOT DONE OR SIDE VARIED=—specify which and give reason: SAMPLE NO. (1-5) HEALTH EXAMINATION SURVEY—III TREADMILL OBSERVER ROOM TEMPERATURE (F°) HUMIDITY ARE YOU ON A SCHOOL TEAM? WAS TEST SATISFACTORY? V[[] ¥88 oie 1p ype Wht Toum® 2] no 1 [J ves 2 [] HO ccmiunere JE NO, explain SPIROMETER ROOM TEMPERATURE (©) WAS TEST SATISFACTORY? 1 [J ves 2 [INO — if NO, explain GRIP STRENGTH YOUTH IS: 1 [] RIGHT-HANDED 2 [] LEFT-HANDED RIGHT LEFT 1. 1 2. 2. 3. 3. Max. Max. 3 O USES BOTH HANDS ABOUT SAME AMOUNT WAS TEST SATISFACTORY? 1] ves 2 40 ccm. WF 1G, OAPI SAMPLE NO. (1-5) 65 66 HEALTH EXAMINATION SURVEY—I1I COLOR VISION EXAMINER NO REPORT Wears glasses for test: OJ COLOR VISION TEST NO. 2—H-R-R (Continued) Wears contact lenses for test: 2 0 PLATE | In mn v Wears neither for test: 3 i] v1 [1] [4 COLOR VISION TEST NO. 1—Ishihara binocular test Z ol 1 [1] [J other PLATE READ AS 1 O12 [] Other 8 2 O 8 O 3 O Other Mi. 4 Os [02 [Jother fs ? 8 Oe [J] other 10 Os [] Other 10 [1 other 14 [] other Os 17 OJ 42 O02 042 11 [J Other O« 042 12 LH [] oth er O Other ME Mod. SCORE: (If total score for plates 2-17 is 6 skip to page 2 of Vision R-G 13 ©] [] other Form) COLOR VISION TEST NUMBER 2—H-R-R 14 HY [J Other PLATE | n 15 [J Other 1 Other i [[] 16 [of | [J other BY Lv LL 2 ©) [J Other SCORE: (7 through 16) High= [] Protan [] Deutan 3 2] [J other X 3 EEE Mod v ™ lpg BE 4 Oth 18 Other i na b : Zl: 19 O Other 5 jo Od Other bu [Iv] [ ¥] - Xi 20 [J Other 6 0 Other X SCORE: (17 through 20) SCORE (1-6): High= [] Tritan [7] Tetartan SAMPLE NO. (1-5) HEALTH EXAMINATION SURVEY—III DISTANCE VISION—WITHOUT CORRECTION VISION TESTS Check tests given first. C Far O Near (Odd numbers distance first; even numbers near first) DIAL 1. BINOCULAR LATERAL PHORIA—DISTANCE (Check number nearest arrow) Owesors OO O22 Os O«4 OO 20 Oz O° Os On Ow O22 Dwr Qu Ow Oe 7/0 Qw Ov OJ On [J Right of 21 [] Arrow or number not visible. Code 2. MONOCULAR DISTANCE—SMALL* 3. MONOCULAR DISTANCE—LARGE* (Omit if score on Dial 2) Line | Right eye od Left eye Score Line [Right eye Score Left eye Score i 5 | VHDNS OZKRC _50 | CDZNO KSRVH ___ 50 1 SDK ——400| VNC —400 6 | DVINC SRHKO __40 | CNRKH ZVSDO__ 40 2 | |[RCSZO OZNKS es 200 e200 7 | KNZCO SRDHV _30 | DVHCK OZNSR_—_30 2 | DRHCV 8 | KNDRS ZVCOH _25 | CDKRO SZVNH ___ 25 3 |HNZOS KRCVD ___100| RZOHC KSNDV.__100 9 | VICHD KNRSO___20 | CVYHSZ ORKDN__20 4 |ZHODC SVNKR — 70| RKNCZ HSDVO_—— 70 10 | KZSVN HCRDO __17 | DNVHS OKRCZ.__17 11 | RCSNY KDHOZ _15 | ZHODC SVNKR——15 12 |ROKHZ NSCVD __12 | KHOZD CSNVR — 12 CODE CODE TRIAL LENS FOR MYOPIA (Score in lines 1-8, Plates 2, 3—OMIT IF CONTACT LENSES ARE WORN.) Rghtee [1 OO O O O O O O score 0 1 1.5 2 3 4 5 N.A. Left eye 0 a 3 a O a O O SCORE 3A. BINOCULAR DISTANCE—SMALL* 4A. BINOCULAR DISTANCE—LARGE® (Omit if score on Dial 34) Line Score Line Score 5 OSDNH VKZCR — 50 1 KDS iii AOD) 6 RHZCD OSVKN _—_ 40 2 | ZSKCO _ 7 SVNHO KCRDZ — 30 2 VRHDN 8 RHSCK OZDVN —_ 25 3 ZNSKH VDRCO — 100 9 OZRVN HSCKD — 20 4 OZCRH NSKDV — 70 10 DRHVN ZSKCO —_ 17 1" OSKCV RZHDN —_ 15 12 SKHDN OCVRZ —_ 12 Code *Diagonal line through each letter missed; horizontal line through sections of line not attempted and through top full line not attempted. SAMPLE NO. (1-5) 67 68 HEALTH EXAMINATION SURVEY—I1I NEAR VISION—WITHOUT CORRECTION 6. BINOCULAR LATERAL PHORIA—NEAR (Check number nearest arrow) Dwiery Oy D2 Oa Oe Ds. Oe Oz/00s Je Dew On Ov Qe Oe Cis Owe Ow Ow Ow O20 O20 O20 024025 O20 27028020 [(Jso [O31 [J32 [33 [J Rrightof33 CODE 7. MONOCULAR NEAR—SMALL* 8. MONOCULAR NEAR—LARGE* (Omit if score on Dial 7) Line Right eye Score Left eye Score Line Right eye Score Left eye Score (Check) 5 | CVRZS DKHNO ___50 | ZKCRY OHSDN __ 50 1 NCV — 400 | DSK —— 400 6 | VZKCO HRSDN ___40 | SDKVO ZRHNC __ 40 2 || HNRCD CRSZO 7 | HSZKN OVCDR ___ 30 | DHZRV SOKNC 30 | 2 | VOSZK wa 300 NDVHK nae 200 8 | OVRHS CNDZK ....25| DKOSN RVICH ....25 3 | NDOCV RSZKH ___ 100 | OKZHS NCVRD wines FOO 9 | ZHCOR VDNSK ____ 20 | RKZVD OSNCH ___20| 4 | VRCNZ OSDHK — 70 | RCOVN DHKSZ ) 10 | RHCVN SDKZO ____17 | OKSRN DHVCZ __ 17 11 | CNZSR OHKDY ——— 15 | VRCHN OZKSD 15 12 | ODCNH VRSKZ —— 12 | ROHKS VDNCZ ____ 12 CODE: secesmvmssamire CODE 9. BINOCULAR NEAR-—SMALL* NS5. BINOCULAR NEAR—LARGE® (Omit if score on Dial 9) Line Score Line Score 5 OCVKR ZNSDH we 30) 1 NVC — 400 6 ZHOCV NDRKS 40 2| czHsN | 7 SDOVK HRNZC — 30 2 | DKORY | s=si200 8 DNHKO ZSRVC ssi 5 3 KSDVO NHZCR mins 100 9 DSVKH ZNOCR soins’ 20 4 VZOCS HRNKD — 10 NZHKO RCVDS 3 1 SNCZO RKVHD re. 15 12 DHNVO SCZKR wei; V2 CODE *Diagonal line through each letter missed; horizontal line through sections of line not attempted and through top full line not attempted. NEAR VISION—WITH CORRECTION 6. BINOCULAR LATERAL PHORIA—NEAR (Check number nearest arrow) Owner Oy O2 Oz: O44 Os Oe O7/0: Oe Owe On Oz The ha Ow Owe Ow Owes Owe O20 O2r O22 as 24 Das O26 27 as ae Oo Ox Os Os: O Right of 33 [J Arrow or number not visible CODE SAMPLE NO. (1-5) HEALTH EXAMINATION SURVEY— III CORRECTED VISION DISTANCE VISION—WITH CORRECTION 2 [3 Wa glanes 2 [] With contact lenses VISION TESTS DIAL 1. BINOCULAR LATERAL PHORIA—DISTANCE (Check number nearest arrow) [J Left of 1 Oy O22 Os: O« Os/06 Oz Os Oe Ovo On Ow Owe Ow Os Thies Ow Che Oe O20 Oa O Right of 21 O Arrow or number not visible. Code 5A. MONOCULAR DISTANCE —SMALL* 3. MONOCULAR DISTANCE—LARGE®* (Omit if Score on Dial SA) Line | Right eye ro Left eye Score | Line | Right eye Score | Left eye Score 5 |KDZNV SHROC___50 | CRNDO SVZHK __ 50 1 | SDK 400 | VNC 400 6 | VKRNZ CODHS ____40 | ZVCOH DRSNK ___ 40 | 2 ||RCSZO OZNKS wes 200 ——200 7 |HSDRZ NCVOK __30 | ZKHSO VCDRN ___ 30 | 2 || KNHDV DRHCV 8 |ZOVCS NRKDH __25 | HNVZS CKRDO __ 25 3 | HNZOS KRCVD____ 100 |RZOHC KSNDV_—_ 100 9 | RHSDK ONCVZ _20 | RHCYN ODSZK ___ 20 | 4 |ZHODC SVNKR ___ 70 |RKNCZ HSDVO__ 70 10 | KNRZD OHVCS 17 | KRNHC OSDVZ___ 17 CODE cmmemrive CODE wermmmmmton 11 | KZODR HNSCV ___15| SCHZD VKNRO __ 15 4A. BINOCULAR DISTANCE—LARGE* (Omit if scare on Dial 34) 12 |RYNSZ KCDOH __12 | CNDZK OHRVS __ 12 3A. BINOCULAR DISTANCE SMALL" kv Sos . 1 KDS — 400 Line Score 2 ZSKCO ern 200 2 VRHDN 5 OSDNH VKZCR 50 3 ZNSKH VDRCO sins 100 6 RHZCD OSVKN 40 4 OZCRH NSKDV — 70 7 SVNHO KCRDZ —30 8 RHSCK OZDVN — 5 CODE LENSOMETER READINGS 9 R H - DZRYN HSCKD 20 EYE LENS | + FIRST READING |[- SECOND READING] AXIS 10 DRHVN ZSKCO emis WE, Right 1 OSKCV RZHDN w— 15 12 SKHDN OCVRZ 12 Left | *Diagonal line through each letter missed; horizontal line through sections of line not attempted and through top full line not attempted. TRIAL LENS TEST FOR MYOPIA (Score in lines 1-8, plates 5A, 3) Righteye [J O Od 5 a O Od O SCORE cmmemimemssmmsenes 0 1 15 2 3 a 5 N.A. Lefteye [J 3 O Od 0 3 il O SCORE SAMPLE NO. (1-5) 69 70 HEALTH EXAMINATION SURVEY—III VISION—LANDOLT RING TESTS WITHOUT CORRECTION DISTANCE* (at 10 feet) WITH CORRECTION 1 [J With Glasses 2 [] With Contact Lenses LINE (Code) | RIGHT EYE LEFT EYE | BINOCULAR LINE (Code) | RIGHT EYE LEFT EYE BINOCULAR 1 200 [J [20 [OO |200 0O 1 200 [O | 20 [O]20 0 2 wo [J |1wo O [100 O 2 wo [OO [100 [Oo [OO 3 na 0O 71.4 O 7a OO 3 7vs OJ ria OO 74 [J 4 so OO) so O|s O 4 so [OJ TE TE 5 393 0 | 393 O | 303 O 5 393 OJ 393 OO | 33 O 6 286 [1 | 286 [0 | 286 0 6 286 [J 286 [J | 288 [OO 7 2s O | 25 O25 O 7 2s [O 2s Ot. DO 8 gig [| 21a O [2a TO 8 na [J gia OO 214 OI 8 ie OO | 179 O | 179 O 9 179 O we OO we O 10 4s [J | wa OO 143 0 10 143 [0 143 [J] ws O 1" 107 OI 107 O voir Cl 1" 07 O oz OO | wz O CODE CODE TRIAL LENS TEST FOR MYOPIA —without correction (Score in lines 1-8 Monocular Distance—Omit if contact lenses are worn) OO OO OO QO og OO 13 sco Right eye Left eye 0 1 1.5 2 3 4 5 N.A. OO. 0 0 0 9 a oslo sooe NEAR* (at 14 inches) TRIAL LENS TEST FOR MYOPIA — with correction (Score in Lines 1-8, Monocular Distance) LINE (Code) | RIGHT EYE LEFT EYE BINOCULAR 1 200 [OJ 200 [J 00 [1 | Nahteve [] N obo ob 2 160 [I 160 [J 160 [J 9 ! 1s 2 : 3 125 0 ws OO 2s OO (‘fe OO o oo 4 100 OO wo OO) 100 OJ [righteye 0 [J [I score 5 so [J so [J go [J a 5 NA. 6 eo [J so [J 60 0 | tereye [J 0 [0 score 7 so [J so OJ so OJ LENSOMETER READINGS (glasses, contact lenses) 8 40 Oo 40 u 40 0 EYE LENS | {FIRST READING + SECOND READING AXIS 9 30 O 30 [OJ 30 10 25 [J 2s [J 2s [0 Right n 20 [O 20 [J 20 © CODE Left *Check acuity level reached. SAMPLE NO. (1-5) HEALTH EXAMINATION SURVEY—III ENT EXAMINATION R L R L EXTERNAL EAR (Except Canal) a 1 [J No FINDINGS 1 [0 1 OJ operative scar 20 2 [[] FINDINGS 2] 2 [] OTHER (Describe): Occluded: Occluded By: R L R L R L AUDITORY 1 [J 1 [J] No FiNDINGS 10 1 [] parmiany 1 [J 1 [] cerumeN CANAL 2] 2[] mnoiNGs—— [2 [] 2 [] coMPLETELY 2 [] 2 [] OTHER (Describe): DRUM R L R L Perforated: x3 “v0 RL ue) vO v[] reo R i R L 2 [] 2 [[] meansearent 20 200 SREdLOR. 1[] 1] wm oiscuasce 1[J 1 [J No FINDINGS ATIONS + [0 230% 10 10 sume [OJ [0 awe 2] 2] FNOINGS— 5 | 2 [J 2 [] semacren 10 v [0] scars 3[] 3[] Not visiLE 10 [0 sigue 10] 1 [[] OTHER AINDINGS (Describe): DRM MOBILE TONSILS: 10 10s 2[] 2[]n0 1 [J] NOT VISIBLE a[] a [PNEUMATIC OTOSCOPY UNSATISFACTORY 2 [[] TONSILLAR TAGS PRESENT ORAL PHARYNX 1 [J No FINDINGS 3 [[] TONSILS PRESENT—GRADE | (Within Tonsillar Pillars) 2 [[] FINDINGS (Describe): - 4 [] TONSILS PRESENT—GRADE II (Outside Tonsillar Pillars but not Meeting in Midline) 5 [[] TONSILS PRESENT—GRADE Ili (Meeting in Midline) NARES OBSTRUCTION: OTHER SIGNIFICANT FINDINGS: R L R L RL 10 Ove 1[J 1 [J No FINDINGS 10 10 acve 2] 2 [J Yes (Describe) 2[] 2[]mnoNes— | 2] 2[] cHroNiC SAMPLE NUMBER (1-5) 71. 72 HEALTH EXAMINATION SURVEY==11l PHYSICAL EXAMINATION EYES: A, LIDS, CONJUNCTIVAE AND SCLERAE B. PUPILS AND IRIDES | Describe: R L R L I escribe: B » 3 bi 10 1 [J No FinbiNGs 103 10] ve somes } ] 2] 2[] FINDINGS (Describe): 55. af Pes sasp | C. TROPIA (indicate direction) D. EXTRAOCULAR MUSCLES AND CONJUGATE GAZE NORMAL IN out up DOWN R L | R50) 203 sf] 4 50 id 1 [J NormAL Describe: Lt 3 203 00 a0) LJ a[] 2 [] ABNORMAL I E. OTHER EYE ABNORMALITIES = 10 we 2] ves (pescrive) THYROID: “GOITER CLASSIFICATION “OTHER THYROID FINDINGS 1[]no | 2 0 VES (Describe) o [] Group © 2] coup 2 1] oroup 1 3 []orour 3 BREAST: ; R L MALE FEMALE LCI somes MATURATION STAGE: | i il Ww v 2] a0] woes: Re 10 20 0 «0 sO GYNECOMASTIA: R L td 20 sO «0 sO CLASS | — wir tenoerness 1] i] OTHER BREAST FINDINGS: — No TeNbERNEss 2] 1] 1] No FiNDiNGS CLASS If — with Tenderness a] s[] il os . = NO TENDERNESS 4 a R " SS i Od 0 WC 10] wes OTHER FINDINGS: i iO a[] a] 2[] Other (Describe) Describe HEART: ’ ” P.M.L INTERSPACE: [4 Os Cs 1 [wor faut MIDELAVICULAR LINE 1 [AT a] insioe 3[Joursice 4[ Nor Feit THRILLS: 4 [assent 1] svstouic 2[_] biAstolic 2 [7] present si | 1 [7 ase 2] apex HAR Ts HEART SOUND 1] NommAL 0 OTHER (Describe): 0Ujiot 2nd HEART SOUND 1] NORMAL 2] OTHER (Describe): MURMUR — TT | OTHER MURMURS: : i [] Assent 1 [J sioNiricaNt 2 [] PRESENT == { 2 [] POSSIBLY SIGNIFICANT 3 [] innocent Describe Mutmur (Location intensity, pitch, guality, duration; time, transmission): OTHER CARDIAC OR CARDIOVASCULAR FINDINGS 1 0 NO 2 [] ves (Describe) 1 [J assent 2 [] present DESCRIBE (As Before): SAMPLE NO. (1-5) PHYSICAL EXAMINATION (Continued) ABDOMINAL: 1 [] AppeNDECTOMY HERNIORRAPHY (inguinal) 1 [] OTHER ABDOMINAL FINDINGS 1 [] wok 2 [err (Describe): 2 [0 908 facia 1 [[] NO FINDINGS 2 [|] FINDINGS esr] (Check all items that apply) GENITALIA: ) | il i Iv v PUBIC HAIR MATURATION (Stage): 1d 2] a] a] s(] MALE: A. GENITAL MATURATION (grade): nl a7 si aC sClv B. circumcision 1[] ves 2[] nO k C. OTHER GENITAL FINDINGS: 1 [] No FINDINGS MUSCULO-SKELETAL 1 [1] no finonos 1 [J 1 [J unoescenoeo tesricte 2 [[] 2[] ofHer (Describe): 2 1 FINDINGS ssmssconissmsscsinisias 1 2 [] FINDINGS (List and Deseribe): SKIN FACIAL ACNE=GRADE oO | I 11] o[] 10 2] 3] a] OTHER SKIN FINDINGS: 1 [] No FiNDINGs 2 [] FINDINGS (Describe): Iv PREFERENCES: ] VERGE . RIGHT (PREDOMINANTLY) LEFT (PREDOMINANTLY) EQUAL UNSATISFACTORY HAND [0 2] a] «J EYE 1] 27] 3s] 4 a roor [J 2] 3] «0 ABNORMAL NEUROLOGICAL FINDINGS 1] None 2 [(] Yes (Describe) OTHER SYSTEMS (Reticulo endothelial, G.l., etc.) 1 [[] No FINDINGS 2 [[] FINDINGS (Describe) NUTRITIONAL APPRAISAL (Your own subjective appraisal) 1] Normal 2] UNDERWEIGHT 3 [| MODERATELY OBESE 4 [ | VERY OBESE BLOOD PRESSURE TIME SYSTOLIC DIASTOLIC TSAMPLE NO. (1-5) 73 74 HEALTH EXAMINATION SURVEY—III SUMMARY OF DIAGNOSTIC IMPRESSIONS X [[] Essentially a normal child with none of the findings below. List all significant findings CARDIOVASCULAR SYSTEM 1 [J NO FINDINGS 2 [J FINDINGS —= List and Describe (include ECG and X-ray findings if noted): DIAGNOSTIC IMPRESSION NEUROLOGICAL CONDITIONS 1 [J NO FINDINGS : 2 [J NEUROLOGICALLY SUSPICIOUS BUT NO DEFINITE ABNORMALITIES (List and Describe): 3 [J NEUROLOGICALLY ABNORMAL (List and Describe): MUSCULO-SKELETAL 1 [J NO FINDINGS 2 [J] FINDINGS (List and Describe): DIAGNOSTIC IMPRESSION OTHER SYSTEMS 1 J NO FINDINGS 2 [J FINDINGS (Describe): DIAGNOSTIC IMPRESSION SAMPLE NO. (1-5) HEALTH EXAMINATION SURVEY—III NURSE'S QUESTIONNAIRE (To be asked of female examinees only) 1. HAVE YOUR MONTHLY PERIODS STARTED, THAT IS, HAVE YOU BEGUN TO MENSTRUATE? 1[JYes 2[JNO 3 [] DONT KNOW (If YES, skip to (If NO or DON'T KNOW, ask Question 2 and discontinue interview.) Question 3.) 2. HAVE YOU BEEN TOLD ABOUT MENSTRUATION IN GIRLS? 1 [J YES 2 [J NO 3 [] DON'T KNOW IF YES,” ask: WHO WAS IT THAT GAVE YOU YOUR FIRST REAL INFORMATION ABOUT THIS? 1 [J Your Mother 5 [] School Program Person 2 [] Older Sister 6 [] Girl Friend 3 [J] Other Member of Family 7 [] Other (specify who): 4 [] Your Doctor or Nurse 3. WERE YOU TOLD ABOUT MENSTRUATION IN GIRLS before the time WHEN YOUR PERIODS BEGAN? 1[JYES 2 [JNO 3 [J] DONT KNOW. A. FROM WHOM DID YOU GET YOUR FIRST REAL INFORMATION ABOUT THIS? 1 [J] Your Mother 5 [] School Program Person 2 [] Older Sister 6 [] Girl Friend 3 [] Other Member of Family 7 [] Other (Specify who): 4 0 Your Doctor or Nurse B. WHOM WOULD YOU PREFER TO HAVE GIVEN YOU THIS INFORMATION? 1 [J] Your Monther 4 [] School Program Person 2 [] Older Sister 5 [] Girl Friend 3 [J] Your Doctor or Nurse 6 [J Other (Specify who): 4. HOW OLD WERE YOU WHEN YOU STARTED? (5. WHiN DID YOU HAVE YOUR LAST PERIOD? years is tines VORHS -_ daysago 6. HOW LONG DOES YOUR PERIOD USUALLY 7. HOW MANY DAYS ARE THERE BETWEEN YOUR PERIODS? LAST? —————— Days | = Days 8. DO YOU SOMETIMES HAVE DISCOMFORT OR PAIN IN CONNECTION WITH YOUR MENSTRUAL PERIOD? 1 [J Yes IF YES, then ask: 2 [J NO : } A. DO YOU HAVE THIS DISCOMFORT 1 [] Most periods 2 [] Occasionally B. IS THIS DISCOMFORT 1 [J Mild 2 [J] Moderate 3 [] Severe C. DOES THIS FREQUENTLY CAUSE 1 [J YES—IF YES, what kind? YOU TO TAKE MEDICINE? 2 [J] NO D. DOES THIS CAUSE YOU TO GO TO THE SICK ROOM OR NURSE? 1 [J YES 2 [JNO E. IS THIS FREQUENTLY SEVERE ENOUGH TO CAUSE YOU TO STAY HOME FROM SCHOOL (OR WORK)? 1JYes 2 NO F. HAVE YOU TALKED TO A DOCTOR ABOUT THIS? 1 [J YES 2 [JNO [ore NO. (1-5) 75 Confidentiality has been gssured the parents as set forth in 22 F.R. 1687 DEPARTMENT OF Form Approved HEALTH, EDUCATION, AND WELFARE Budget Bureqy Ho. 68-81700 PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS WASHINGTON, D.C. 20200 HEALTH EXAMINATION SURVEY] REPORT OF FINDINGS EXAMINEE'S NAME AND ADDRESS AGE DATE OF EXAMINATION NAME AND ADDRESS OF PHYSICIAN HEIGHT (inches) © | WEIGHT (lbs.) COLOR VISION VISUAL ACUITY (Distance) [] No defect [7] Not tested RESULTS ARE: [] WITH GLASSES DEFICIENCY Od WITH CONTACT LENSES TYPE SEVERITY [J] WITHOUT CORRECTION [7] Red-Green [J Mild [7] NOT TESTED [[] Green-Red [J Moderate RIGHT EYE LEFT EYE [7 Blue~Yellow [[] Severe 20/ 20/ HEARING: Cycles Decibels Cycles Decibels (audiogram) Per Second Right Left Per Second Right Left 250 3,000 500 4,000 1,000 6,000 2,000 8,000 CHEST X-RAY oo BLOOD CHEMISTRY [[] COPY ENCLOSED HEMATOCRIT 5 [] NOT PERFORMED BACTERIURIA (Females only) . y (POSITIVE—more than 100,000 colonies/cc) PBI(Serum) micro gms % 1st Specimen ; [] Pos. [7] Neg. [7] Not Performed CHOLESTEROL (Serum) ~~ mgms % 2nd Specimen (date performed ) URIC ACID (Serum) mgs % [J Pos. [] Neg. [[] Not Performed SEROLOGY: VDRL [7] Neg. [] WR []] Pos. FTA-ABS [7] Neg. [] WR [7] Pos. See enclosed Form for notes on tests used. SIGNIFICANT MEDICAL FINDINGS—for which parent gave ne history and which may require medical follow-up: NO. (1-5) Confidentiality has been assured the parents as set forth in 22 F.R. 1687 DEPARTMENT OF Re HEALTH, EDUCATION, AND WELFARE Budget Bureau No. 68-R1700 PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS WASHINGTON, D.C. 20201 HEALTH EXAMINATION SURVEY—I1I REPORT OF DENTAL FINDINGS EXAMINEE'S NAME AND ADDRESS AGE ) DENTIST NAMED BY PARENT DATE OF EXAM. THE INDEX ASSESSMENTS USED IN THE SURVEY REVEAL: [J No conditions which suggest that the Examinee should be seen by you before the next regular appointment. ONE or MORE of the FOLLOWING CONDITIONS that suggest a clinical examination is desirable to determine whether or not treatment is needed before the next regular appointment. [C] DECAYED TEETH [] GINGIVITIS and/or PERIODONTAL DISEASE [] ORAL DEBRIS and/or CALCULUS [] MALOCCLUSION [7] OTHER CONDITIONS (specify) COMMENTS STUDY NO. (1-5) GPO : 1967 0—237-397 Confidentiality has been assured the individual as set forth In 22 FR 1687 DEPARTMENT OF HEALTH. EDUCATION. AND WELFARE Porm Approved’ PHS-4611-5 PUBLIC HEALTH SERVICE Budget Bureou No. 68-R620-S4.5 3-65 NATIONAL CENTER FOR HEALTH STATISTICS 8 2 2 DENTAL EXAMINATION — HEALTH EXAMINATION SURVEY z Name DAE OH BINAL ery oF VETR I. SAMPLE NUMBER ——> 2 EXAMINER =cf== 2: =3=- RECORDER :=:b:= 2: =3: oO t= 3 : 4 S&H: =F BE Ston sr Br ofr 7: Be Ar Br Er Tr 8 © t 2 a 5: fr nf § 9 3.EDENTULOUS ARCHES -DENTURE STATUS oO pei EE 3 we HB: Hr =P: =: > Absent Present Defective Upper $oes: rho Bie ° j= spe ape Te #5 wr nf: Er of Examinee Lower sie seem smn o fr ug oF 2 8: 3G afc EE 3G 4, STATUS OF TOOTH SPACES Err No zx: Primary Teelh Teeth Present Permanent Teeth Missing INDEX | P.I. Tt o Non-Functional § Cxiracfedz! . . ; Quadrant | & 5 = Tooth 2 A gCarious | Tooth [£83 y 13 Tooth z z 3 2.32 3 $2 2 2 3 ick gE; if i 2 & S « Space 38 £ 2 | space [585 £ Sl Space 3s 5 & P XP XR D F XR MSC 0 Cc S-X R | 2 6 8 3rd Molar = =z}:z|3rd Molar | 24 zzfaz =| 3rd Molar =f 2nd Molar sR: 2: 2: =2:2ndMolar| 2: =|2nd Molar =: Ist Molar 3%: Be =3::|Ist Molar| =3-- =| Ist Molar =] UPPER | 4 4: 4 2nd A-londBi | 4 | 2nd Bi wh ARCH “6: B= 6 Ist Bi Beaist BI |= 8e: -| Ist Bi =: RIGHT “B= B= 6B Cuspid B= B= Br Hr BCuspid =| Cuspid Br Br Bs sf of 7: Leteral P= Fs =F =7- =T-|Lateral |=7-- Lateral ef: Pr uf: 8: 8 Central Bx 8: BB: B:Central |B: =| Central 2B: a8: 8: 8: N 0D PF XD | 2 6 8 =Q:- 9: -Q:| Central Pr 9: ®: 9: :9::[Central |: 9: -| Central w§: 39 =P: 9: +0: #0: +0: Lateral +0 #0: +0: +O =kO:fLateral [HO -| Lateral HE HG 4G 4G UPPER shh Hh: -b:t:| cuspid sith hb: chi: skh cibeCuspid [zh Cuspid safe mists oii Tie ARCH +2: *2- +27 Ist Bi +2: +2-|Ist Bi -| Ist Bi 42: 2 LEFT +3: +3: +3 2nd Bi #3: #3: #3:ondsl [:hE: 2nd Bi st: 45: Ist Molar +4: +4: kd: 4: k4:list Molar| Fd: H4:- Ist Molar $4: hd: 4d: hd 2nd Molar %5: $5: #5: 45: #5: #5: HS: Se +5: 2nd Molar #8: 5: AS 45 3rd Molar +6: +6: +6: #6: +6:3rdMolar| +6: 46: 46: A6: :k6:|3rd Molar +6: 6: 48: 46: P XP N D F XD 0 Cc $-X 3rd Molar Zr FF: ®F: FZ: £F:BdMolor[P: $F: £F: HP: Zz) 3rd Molor 2: S$: HE: 4F: 2nd Molar +8: 48: 48: 48: +8 18: 48: +8-| 2nd Molar #8: 8: HB: iB: LOWER Ist Molar +9: 9: $9: 49: +O:fist Molor[kO: 49: 4: +9:| Ist Molar HS: HS: HS: +9 ARCH 20 20 20 2ndBi 20: 20: 20 20 20]endBi |2© 2nd Bi 20 20 26 20 LEFT Be 24 24 191 BI Sis 2d Bk Be fad |S -| Ist Bi 2+ B24 24 D4 22: 22 =| Cuspid 22 22 22 22 22|Cuspid |22 22 22 22-|Cuspid 22 22 22 2% 2% 23 -| Lateral 2% 2% 23 2% 2Fldenl|2EZ 323 2%: 23: 23:lLeteral 23 23 23 23% 24: 24: Central 24: 24: 24: 24 24:Central 24: 24: 24: 24 24:|Central 24 24 24 24 N 0 F XD 0 C $-X R | 2 6 8 Central 25 25 25 25 25icenrai|25 25 25 25 25 (Central 25 256 25 25 26: 26: -| Lateral 26: 26: 26: 26: 26:|Loteral [26° 26: 26 26° 26:|Lateral 26 26 26 26 LOWER | 2%: 2%: 2%:| Cuspid 2%: 27: 27 27: 27:|Cuspid | 27 27 27° 27:|Cuspid 27 27 2% 2% ARCH 28: 28 28: Ist Bi 28 28: 28 28 28IstBi |28 Ist Bi 28 28 28 28% RIGHT 129: 29: 29 2ndsi 29% 29 29° 29 29{endBi (29 2nd 8i 2% 29 29% 29 Ist Molar 3G 30 30 30 30st Molar| 30: 30 30 3G (Ist Molar 30 30 3¢ IG 2nd Molar BE FB: FB FE Sendmoien Fd: BZ: Fi: 3-4=| 2nd Molar Zr Hf Be By 3rd Molar | 32: 320 32: 320 32:[3rdMolar| 32 32 322 32 323d Molar | 32 32 32 32 DENTAL EXAMINATION =— HEALTH EXAMINATION SURVEY SAMPLE NUMBER nth sr Sr Stand 2:8 modes ze: Examinee Zaz cr i. 6. ORAL HYGIENE INDEX ————————————— Upper Arch Lower Arch Right Anterior Left Right Anterior Left Debris Calculus Debris Calculus Debris Calculus Debris Calculus Debris Calculus] Debris Calculus G None “GF “O° None 0 “Gr None “OF O: None OF: “GF: None “O “G= None HE 43 TEE mp 3 SE mpzz i73 SEE zp 73 == =r 1/3 1/73 Pz 2/3 2: 2: 2/3 an Ze 2/3 3: bo ll 3: 12/3 2/3 TR WWE 42/5 5 Bw 2/5 TEs we 3: +2/3 = +2/3 =3= NA WA WA NA RA NA NA NA A 7. FRACTURES OF ANTERIOR TEETH 8, OPACITIES Upper Teeth Lower Teeth Non- None Dentin Pulp Treated NA None Dentin Pulp Treated NA fluoride |Fluorosis sf wn ugh SpE Eps 25 25% 25 25 2% geoee =zzzz | None gr EG gr 8: 24: 24 24 24 24 szz2z 2zz22 | Mild ig ig iE gE og 28: 28: 285 25 25 Ee Ee Mogeraie= +0: HO: FO: FO HO: 28: 28: 26 26 26 zz [NA 9. BUCCAL SEGMENT RELATION 10. POSTERIOR CROSSBITE 11. INCISOR RELATIONSHIP Openbite (mm) Right | Left Right Left 4+ =f: |Mesial-Severe Lingual Buccal Lingual = 2-4 “2 —Moderate 0=2 <%= |Normal Overbite (mm) <4: |Distal— Moderate = Inc 3rd He: — Severe Mid 3rd IA |Not Applicable = Gin 3rd Tissue [=] == Jprimary Arch Impinging Overblite Not Applicable 12. HLD INDEX (Handicapping Labio—lingual Deviations) Mandibular Labio-lingual Overjet Protrusion Openbite Spread Deformity Gg: 0: Oo: Os $B: Os: Qe: De =z: Absent Zeficy safer Pm ge zzz Present me ul az othe i: “5 ° g H 5: 8 2 Fes =F: Fez = a = 8: 8: “8 9: = 9 =x NA NA NA NA PHS-4611-5 3-65 (Page 2) FEET EE EEE ee ee Er ee ee ee ee ee ee eee ee ee eee 18M H92210 DENTAL EXAMINATION = HEALTH EXAMINATION SURVEY Sz NUMBER ————> Pr oF: 2 285 Stand Hr ile Be mE: ode: =H $B: mf: 3P: Ec odes 25: fe: yz mb oP 1 A 2:8e Examinee ] 2dze Br min: Pr En ole on RE 13, LOWER INCISOR WIDTHS (mm and tenths) 14, INCISAL OVERLAP (mm) 15, SPACE (mm) or al, eu Er [upper leowar = Upper — —Lower — 26 25 24 23 Right Left Right Left Right Left Right Left =O: =r: Bed x 0: 2G: =: 0: ye = =D: Gr zh: zh aja mb ain mfr asd: af safes sds ender 32: =: 2: 2: er Pe pe P= sli ug 38: 23 Be: Be: eB ofr afer Ee : & @ @ B # [+] b ’ Ehohobirin oH 16. DISTANCE FROM LATERAL TO MOLAR (mm) 17, MALALIGNED TEETH Upper Lower Upper Lower Anterior Posterior Anterior Posterior Right Left Minor Major Minor Major Minor Major Minor Major] Kr: 6: FEEEEEREEER EEE eee eee bree eee ieee eee Right $ hbrb pbb ib # hil boro bbboie on bene bebe ih Eg » B 6 Bb Bb Nb NA NA 18. MAXILLARY ARCH WIDTH (mm) 19. ORTHODONTIC APPLIANCES REMARKS: Present zzz: Absent Molar Cuspid zzzzx None =: 2G ==z:= Active- Fixed » » © Fo zzz Active Removable zzz:z Retainer -zzzz Space Maintainer = : . bohbiore 5 zzz Other (describe) § z » PHS -4611-5 (Page 3) 3-65 000 ¥ U. S. GOVERNMENT PRINTING OFFICE — 1969 — 396-235 P.O. 4 Series 1. Series 2. Series 3. Series 4. Series 10. Series 11. Series 12. Series 13. Series 14. Series 20. Series 21. Series 22, OUTLINE OF REPORT SERIES FOR VITAL AND HEALTH STATISTICS 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: 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 vital registration laws and revised birth and death certificates. Data from the Health Intevview 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 Suvvey.—Data from direct examination, testing, and measure- ment of national samples of the 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 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 on 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 Suvvey.—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 manpower occupations, hospitals, nursing homes, and outpatient and other inpatient facilities. Data on mortality.—Various statistics on mortality other than as included in 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 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, medical experience in the last year of life, characteristics of pregnancy, etc. For a listof titles of reports published in these series, write to: Office of Information National Center for Health Statistics U.S. Public Health Service Washington, D.C. 20201 PUBLIC HEALTH SERVICE PUBLICATION NO. 1000-SERIES 1-NO. 8 (Ne IY) oN = NCHS % / 0 LASINA Design and Methodology of the LTR EN CA EH Inventory Survey U. S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Public Health Service Publication No. 1000-Series 1-No. 9 For sale by the Superintendent of Documents, U.S. Government Printing Office Washington, D.C., 20402 - Price 40 cents Data from the Series 1 NATIONAL HEALTH SURVEY Number 9 Design and Methodology of the 1967 Master Facility Inventory Survey A description and evaluation of the 1967 survey, which up- dated the original Master Facility Inventory, together with a summary of the Inventory’s early development. U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Rockville, Md. January 1971 NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, Ph.D., Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development JAMES E. KELLY, D.D.S., Dental Advisor EDWARD E. MINTY, Executive Officer DIVISION OF HEALTH RESOURCES STATISTICS SIEGFRIED A. HOERMANN, Director PETER L. HURLEY, Deputy Director NOAH SHERMAN, Chief, Family Planning Statistics Branch GRACE WHITE, Acting Chief, Hospital Discharge Survey Branch G. GLORIA HOLLIS, Chief, Health Facility Statistics Branch PAULA STEWART, Acting Chief, Health Manpower Statistics Branch Public Health Service Publication No. 1000-Series 1- No. 9 Library of Congress Catalog Card Number 72-605818 PREFACE One of the responsibilities of the National Center for Health Sta- tistics is to gather comprehensive statistics on all types of health fa- cilities and services. The Master Facility Inventory (MFI), which is a statistical program of data collection of all inpatient health facilities, develops a list of such health facilities, A continuing effort is made to keep this list current. To this end, a survey of the MFI is conducted biennially, and an Agency Reporting System (ARS) has been developed to provide information on new institutions. The maintenance of the MFI was made possible through the cooper - ation of many individuals who completed questionnaires in a 1967 mail survey of inpatient health facilities, and of a number of agencies which provided lists of health facilities from which the mailing list for the survey was compiled. Their cooperation is gratefully acknowledged. In this survey of hospitals and inpatient facilities conducted by the National Center for Health Statistics (NCHS), assurance was given that "the statistics will be presented in such a manner that no individual facility can be identified." Therefore NCHS will not publish a directory of establishments. The U.S. Bureau of the Census made especially valuable contri- butions to the 1967 MFI Survey, which included such operations as matching the names of hospitals and institutions on different lists to eliminate duplicates and the collection of data from establishments to determine their current status and nature of business, Overall plans for the 1967 MFI survey, including the development of procedures and general specifications for collating lists and survey- ing establishments, were the responsibility of the National Center for Health Statistics and were developed under the supervision of Peter Hurley with the assistance of James Del.ozier. This report was prepared by G. Gloria Hollis, SYMBOLS Data not available--=-=~==emmm mm —mom———— Category not applicable---c--ecmemmcceaaoa- Quantity Zero---=-rmmmmmmmmem meee Quantity more than 0 but less than 0.05---- Figure does not meet standards of reliability or precision----=-ececceeeoan- 0.0 CONTENTS Page Description of the Master Facility Inventory------=-=-=cecmmmemmc emcee 1 Explanation of the MFI-------cmmmmmm mmm meee 1 Purposes of the MFI-----mocommmm eee eee 2 Background --=--==== oom mmm meee ee eee 2 The Agency Reporting System---------c-cmommmm ccm mm meme 2 1967 MFI SUTVEY === == === m mmm mmm mm mmm ee eee eee eee 3 SUMMATY === === == === =m mmm mm mo mee ee eee eee meme 3 Survey ObjectiVe-===- === mmm mmo moe eee eee 3 Mailing LiSt--=-=-= mmm m mmm mm meme eee 3 Survey Questionnaires----=----=-=-cmmmm mmm eee 4 Pretest------mmm mmm emma 4 Survey OperationS----= == =o mmm eee 5 Facility Classification------=----=ccmommomm ecm ecm eee 10 Survey Evaluation-----=-=-==-cmmcmm mmm eee 10 Response to the 1967 MFI om cm momo eee eee 10 Appendix I, Forms--------cmmmmmmm momma 12 Appendix II. Definitions and Classification Procedures-----------=------ 28 Criteria for Classifying Nursing, Personal, or Domiciliary Care Homes-- 28 Definitions of Other Terms------=----=cccm mmm meme 29 vi IN THIS REPORT is a detailed description of the procedures used in 1967 by the National Center for Health Statistics (NCHS) in a survey to update the Master Facility Inventory (MFI). The MFI is a comprehensive file of inpatient health facilities such as hospitals, nursing cave and velated homes, and selected custodial and correctional institutions in the United States. In order to keep the data in the file current, biennial mail surveys ave conducted of all facilities in the MFI, In addition to a summary of the development of the MFI, this report gives a sequential account of how the 1967 survey was conducted andattempts an evaluation of the results of the survey, DESIGN AND METHODOLOGY OF THE 1967 MFI SURVEY DESCRIPTION OF THE MASTER FACILITY INVENTORY Explanation of the MFI The Master Facility Inventory is a compre- hensive file of those facilities in the United States which provide medical, nursing, personal, or custodial care to groups of unrelated persons on an "inpatient" (at least overnight) basis, It also includes certain residential training facilities and correctional institutions. (For convenience, the term inpatient facilities or simply facilities is used to mean all types of places in scope for the MFI.) In order to keep the MFI current, the entire list of inpatient health facilities is surveyed bi- ennially to update the data NCHS has. At the time of the 1967 survey, the MFI in- cluded the following types of places: 1. Hospitals with six or more beds. 2. Establishments which provide nursing or personal care to the aged, infirm, or chronically ill, These include such places as nursing homes, convalescent homes, homes for the aged, rest homes, boarding homes for the aged, and homes for the needy such as almshouses, county homes, and "poor" farms. In addition to having three or more beds, the primary criterion for determining if such establishments are in-scope for the MFI is their function of providing some kind of care in addition to room and board. See appendix II for a detailed description of the criteria used for classifying nursing, personal, or dom- iciliary care homes. 3. Residential schools or homes for the deaf. 4, Residential schools or homes for the blind. 5. Homes for unwed mothers, 6. Orphan asylums and homes for dependent children. 7. Homes for crippled children, 8. Homes for incurables. 9. Residential schools or detention homes for juvenile deliquents. 10. Prisons, reformatories, and penitentia- ries operated by the Federal or State governments. (The MFI excludes county or municipal jails.) The MFI does not include special dwelling places or group quarters such as hotels, private residential clubs, fraternity or sorority houses, monasteries, nurse's homes, ''flophouses,'" labor camps, etc. The MFI is maintained on computer tape and contains the name, address, geographic area code, and basic descriptive data of each facility. The data for hospitals include ownership or con- trol, major service area, limitation of patients by age and/or sex (if any), number of beds, aver- age length of stay, average daily patient census, and number of admissions. For nursing homes, the data include ownership or control, type of facility, limitation of patients by age and/or sex (if any), and number of beds. For other facilities, the data include ownership or control, type of facility, limitation of inmates by age and/or sex (if any), and number of persons who stayed in the facility. All data in the MFI are obtained directly from the facilities through mail surveys. Purposes of the MFI The MFI has two basic purposes. It is an important national source of statistics on the number, type, and geographic distribution of inpatient facilities inthe United States, In addition, it serves as the universe from which probability samples may be selected for conducting sample surveys, Background The MFI was first assembled during 1962- 1963. During this time a series of mail surveys were conducted after succeeding stages of de- velopment to determine the current status and nature of the places added to the MFI, Facilities were also added during 1964 and 1965. Up to the time of the 1967 MFI survey, the MFI had been used as the sampling frame for three major surveys—the Hospital Discharge Survey, the Resident Places Survey 1, and the Resident Places Survey 2. (Further information on the MFI, its purposes, and its development from the 1962- 1963 surveys may be found in NCHS publication Series 1-No. 3).? One of the difficulties with this developmental stage of the MFI had been the lack of any means of updating the file, As changes rapidly occur among inpatient health facilities, it was neces- sary to develop some means to keep the MFI current so that the Center would have accurate data on these facilities, In addition, since the MFI is used as the universe from which proba- bility sample surveys are drawn, it is imperative that it be an up-to-date list of facilities, properly classified and accompanied by critical identifying attributes, such as number of beds. Therefore two methods have been developed to keep the MFI current. The first of these, the a National Center for Health Statistics: Development and maintenance of a national inventory of hospitals and insti- tutions. Vital and Health Statistics. PHS Pub. No. 1000- Series 1-No. 3. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1965. Agency Reporting System, is a program for de- termining the names and addresses of all newly established inpatient health facilities, The second is a continuing series of biennial surveys of the MFI to gather current data on the facilities, During 1966-1967, the MFI was first updated with the Agency Reporting System, by using lists and directories of hospitals and resident facilities - provided by various city, State, and Federal Government agencies. In August 1967, the second method of updating was initiated, with a survey of all MFI establishments, using a mailing list complete as of January 1, 1967, This report will describe in detail the methodology of the 1967 MFI survey, the first of the biennial updating surveys, and attempt an ob- jective evaluation of the results. The Agency Reporting System An increasing number of new hospitals and institutions begin operation each year, many go out of business, 'and ownerships, names, and services offered to patients change frequently. This is particularly true with regard to nursing and personal care homes, which comprise more than half of the MFI, Therefore, as mentioned above, some updating procedure was necessary between the biennial MFI surveys if the inventory was to remain complete for any length of time, The main concern in updating the file was to identify new facilities. Other changes, such as name and address changes and facilities going out of business, could be made through direct contact with the facilities in the biennial surveys of the MFI, It was decided that an input system at the State level was needed to keep the MFI abreast of these changes because nearly all facilities in the MFI are regulated or controlled by one or more State agencies, This decision led to the development of the Agency Reporting System (ARS), which includes State agencies which ad- minister, regulate, certify, approve,list, or are otherwise concerned with medical and resident care facilities; national voluntary organizations and Federal and State agencies, including health, welfare, and voluntary religious organizations; publishers of commercial directories; and Fed- eral agencies that administer inpatient facilities, At regular intervals, these agencies send the Center lists of new facilities to be added to the MFI, These lists contain such information as name, address, type of institution, and owner- ship. The ARS is subdivided into two information files. A Basic Information File is maintained to record information about each type of facility within each State, The Basic Information File provides information from each State and the District of Columbia on each type of facility listed in the MFI and also on the lists from which each type of facility is enumerated. The Reporting Information File is maintained to assist in mailing letters and recording re- sponses from each of the agencies in the ARS, It is a control record of 'who'' sent in ''what," "when." For a detailed account of the develop- ment of the ARS, see NCHS publication Series 1, No. 6. 1967 MFI SURVEY Introduction The 1967 MFI survey was conducted during August-December 1967 by the National Center for Health Statistics with the Bureau of the Census acting as collecting agent. It was a mail survey consisting of an original mailing, two mail followup inquiries to those facilities that did not respond to the previous mailings, and an intensive telephone and personal visit followup to those facilities that still had not replied after all three mailings, Questionnaires were sent to 44,097 addresses; 31,292 were considered actively engaged in providing inpatient care at the time of the survey, of which 29,269 (or 94 percent) facilities returned the questionnaires. The remaining 6 percent either refused to respond or were never heard from during the repeated followups. National Center for Health Statistics: The agency report- ing system for maintaining the national inventory of hospitals and institutions. Vital and Health Statistics. PAS Pub. No. 1000-Series 1-1Jo. 6. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1968. Survey Objective The primary objective of the survey was to collect current statistical data from those facili- ties in the MFI that were in business, In addition, the NCHS wished to have sufficient data available from each facility to enable use of the MFI as an efficient sampling frame for sample surveys of hospitals and other medical and paramedical inpatient facilities, Toward these ends, the survey was designed to: 1. Obtain current statistical data from each facility. 2. Obtain adequate identification information to eliminate duplication within the MFI and to enable easy identification and location of each facility, A facility may be known by two different names, which might lead to inclusion of the facility on a list under each name. If other data, such as address, type of service, etc.,, Were available and could be compared in such instances, it would be possible to eliminate duplicates. 3. Obtain maximum response in order that the MFI might be as complete as possible. 4. Obtain data to classify each facility for sample survey stratification, For ex- ample, the type of facility, such as long term hospital or personal care home, and the bed size are variables often used in sample stratification. Mailing List The mailing list for the 1967 MFI survey was assembled as follows: Through the Agency Reporting System, the NCHS contacted some 350 government and nongovernment agencies which maintain lists or directories of facilities within the scope of the MFI and requested a copy of their lists. Most were State government agencies. All lists and directories were then clerically merged, along with the 1963 MFI, to produce a single large list, as free from duplicates as possible, The names and addresses on the list were edited to a standard format, put onto punch cards, and subsequently put onto computer tape in fixed field records. This latter procedure greatly facilitated the matching of names and addresses to eliminate duplicates, which was done by computer and, when a further clerical check was necessary, by clerks. The telephone number, number of beds, and owner's name were included on the tape record of each facility for use during the 1967 survey. At the time the mail- ing list was compiled, each facility was classified into one of three broad categories: (1) hospitals; (2) nursing, personal care, and domiciliary homes; and (3) penal, custodial, and training facilities. The classifications were generally based on the facility's name or function or other infor- mation available from the lists and directories used in compiling the final mailing list. Thus, a hospital was defined as a facility licensed by the State as a hospital or operated as a hospital by a Federal or State agency. Facilities which pro- vide some form of nursing, personal, or domi- ciliary care were classified according to the primary service provided. (See ''Facility Classi- fication," p. 10.) Penal, custodial, and training facilities were defined as establishments wnich provide services such as training and sheltered care rather than medical or nursing care. This general classification subsequently determined which of the three types of questionnaires these facilities were sent. Survey Questionnaires Because of the heterogeneity of the facilities in the MFI, and the consequent need to obtain somewhat different information from the various types of facilities, three different questionnaires were used in the 1967 MFI survey. The three different forms were designed to survey each of the three broad classifications mentioned above, i.e., (1) hospitals; (2) nursing, personal care, and domiciliary care homes; and (3) other in- patient health facilities, i.e., custodial, training, and Federal or State penal facilities, (See appendix I for copies of these forms.) For brevity, the three classifications are hereafter referred to respectively as "hospital," ''nursing home, and "other." In order to simplify the survey operation, the three quesfionnaires were made as nearly the same as practicable, and, in general, they differ only in a few questions. Each of the three forms requests a consider- able amount of identification information in section A, This section was designed to obtain information which will assure that the facilities are properly represented in the MFI and are listed only once. Name, mailing address, location address, zip code, and telephone number were requested. Cross-checking these items as the survey returns were processed kept duplication to a minimum, Sections B and C differ slightly among the forms. On all three types, however, these sections were designed to obtain some basic data for national statistics on inpatient facilities and to stratify the MFI for sample selection, The final question on each of the three forms was used to detect facilities missing from the MFI, It requests that the owner of the responding facility provide the names of all other facilities he owns. All names and addresses thus reported during the survey were searched on the mailing list and a questionnaire immediately sent to those not found. To the extent possible, the three question- naires were precoded to simplify the data pro- cessing operations; that is, a number was printed beside the answer boxes of most questions, The numbers were then used as the coded answers to be punched directly from the questionnaire. All three types of forms were kept as brief as possible since maximizing the response rate was an important survey objective, Only infor- mation absolutely essential to the survey's ob- jectives was requested. Pretest The questionnaires and mailing procedures planned for the 1967 MFI survey were pretested during March and April 1967. Approximately 350 facilities were chosen at random for the pretest in seven States, and an additional 100 facilities were selected in Boston and New Orleans. Questionnaires were mailed March 1, 1967, and a followup inquiry was mailed to nonre- spondents 2 weeks later, Personal visit inter- views were conducted 1 week later in 23 facili- ties in New Orleans and in 18 facilities in Boston in an attempt to evaluate the questionnaire and survey procedure, Facilities representing all three major classifications of the MFI were visited in these two cities. Some had responded to the pretest inquiry and some had not. Four weeks after the pretest was initiated, about 90 percent of the facilities had responded to either the initial mailing or to the followup inquiry. Due to the lack of problems encountered by the responding facilities in completing the questionnaires and to the low nonresponse rate of 10 percent, a second followup mail inquiry was not sent, The personal visit evaluations also indi- cated that, generally, the questionnaires were clearly understood, and could be quickly and easily completed so that only minor changes were needed for use in the national survey. Survey Operations Timing of mailouts The 1967 MFI survey was launched August 4, 1967. Questionnaires were mailed from the Jeffersonville, Indiana, office of the Bureau of the Census. Following the initial mailing, there were two mail followup inquiries to nonrespondents. The first, consisting of a reminder letter and a copy of the questionnaire, was sent by regular mail Table A. to nonrespondents 3 weeks after the initial mail- out, At that time, 23,372 questionnaires had been returned either by respondents or by the Post Office as undeliverable. The second followup in- quiry, sent 5 weeks after the initial mailing, also consisted of a reminder letter and a copy of the questionnaire, It was sent by certified mail to the 13,014 facilities which had not responded at that time. The final followup procedure for nonrespond- ing facilities was an interviewer followup con- ducted in late September 1967 by the various field offices of the Bureau of the Census. It con- sisted of telephone calls and/or personal visits to the 2,864 facilities not yet heard from. Table A shows the cumulative number and percent of survey returns at selected intervals during the survey period. Clerical editing, coding, and punching procedures As the returned questionnaires were received in Jeffersonville, they were sorted clerically by the three types of questionnaires. Those forms returned by the Post Office and those returned by the respondent as out of business, out of scope of the MFI, etc., were coded as suchand received no further editing, '"Good returns," i.e., those from facilities in operation and in scope of the MFI, were carefully edited by trained clerks following specific written editing and coding in- Number and percent of questionnaires received during each of the stages of the survey Date Total number of question- naires mailed Questionnaires completed and returned Cumulative percent of total mailout Cumulative number received to date August 4, 1967--------c--uun-- 44,097 - - August 25,1967 (first followup) - 20,725 23,372 53.0 September 8, 1967 (second followup)=-=-=-======-=-----cc-ou 13,014 31,083 70.5 September-October 1967 (Census field followup)-----------=---- 2,864 41,233 93.5 structions. In general, the instructions were designed to: ®Determine that all key items were com- pleted properly. For hospitals, these items were: ownership, type of service, age of patients, bed size, average length of patient stay, admissions, full-time and part-time staff, For nursing care andre- lated homes, the key items were: owner - ship, type of service, bed size, number of persons who stayed in the facility "last night," number of persons receiving nurs- ing care, type of services offered, and full-time staff, For other facilities, the key items were: ownership, type of service, age of patients, number of per- sons who stayed in the facility ''last night," and full-time staff, ®Assure that the facility for which the questionnaire was completed was in scope of the MFI, ®Detect any inconsistencies or unreason- able entries, ®Assure that the form contained infor- mation for one and only one facility, ®Determine from the identification infor- mation that the reporting facility was not already on the MFI, ®Prepare the questionnaires so that all data could be easily punched onto cards directly from the questionnaire. When key questions were not completed on a questionnaire, the form was said to have ''failed edit," As it was necessary that data be available for these key questions, the following procedures were used: For hospitals, the missing data were usually ob- tained from the 1967 ''Hospitals Guide Issue" of the Journal of the American Hospital Association, For nonvegistered hospitals and for nursing homes and "other" facilities, missing data were requested from the responding facility by sending them a fail-edit questionnaire requesting only c . American ifospital Association: Hospitals guide issue, part 2. J.A.H.A. Chicago, Aug. 1967. the specific information needed. (Fail-edit forms are reproduced in appendix I.) For those facili- ties not returning the fail-edit inquiry, data were imputed from various other sources whenavaila- ble or were coded as unknown. These ''unknowns'' were then mechanically imputed at a later stage of editing, If a facility was misclassified when the mailing list was prepared and returned an in- correct type of questionnaire, the proper form was usually mailed with an explanatory note. In some instances this was not necessary because enough data were available on the returned incor- rect form to complete the correct one. Most mistakes of this type were made when the hospi- tal form was sent to a nonhospital facility. Of 227 forms of the wrong type sent, 188 were hospi- tal forms, 19 were nursing home forms, and 20 were other forms. Many of these mistakes were attributable to the initial inclusion of all mental facilities in the "hospitals'' category. This meant that some homes for the mentally retarded were sent the hospital form. Many of them returned their form with the remark that they are not a hospital, These homes were then sent the "other" form, After the questionnaires went through the clerical editing and coding process, the data were punched onto cards and subsequently put onto com- puter tape. The effective cut-off date for survey returns was November 17, 1967. All editing, coding, and keypunching, however, was not com- pleted until January 1968, and questionnaires re- ceived after the cut-off date were processed when time permitted. By January 31, 1968, all survey operations being done by the Bureau of the Census had been completed. At that time, the NCHS received from the Bureau of the Census computer tapes con- taining a data record for each of the 44,097 facilities on the original survey mailing list. The data records for those places found to be out of business, out of scope, not responding after repeated contact, etc,, contained only a code indicating such, along with the facility's name and address. For those responding facilities which were in scope of the survey and in business, the data records included the name(s), address (es), and virtually all of the information provided by the respondent on the survey questionnaire, Machine edit and imputations A second edit of the MFI data was then done, this time by NCHS computer processing. This edit was rather extensive and was intended to detect inconsistencies, unreasonable data, cleri- cal errors, and keypunching mistakes made when the data were punched onto cards from the questionnaires. The questionnaires for those facilities which had one or more data items that failed to meet the editing specifications were reexamined and necessary corrections were made to the data tape records. The following are some of the types of edit- ing done by computer processing, along with specific examples of each: Numeric items (such as number of beds, full-time employees, etc.) were examined to see that they did not exceed a specified maximum size beyond which the data would be questionable, Example: Homes for dependent children with more than 200 residents were checked for accuracy by referring back to the entry on the questionnaire, Numeric items were compared with other related numeric items for the facility. Example: Hospital questionnaires were reexamined when the average daily inpatient census was greater than 110 percent of the number of beds or less than 10 percent of the number of beds. Coded items (items suchas type of owner- ship, where a numerical entry represents the respondent's answer) were checkedto see that they fell within the range of per- missible numbers. Anything other than the specific allowable codes was an erroneous entry, All of the above edit checks required reex- amination of the questionnaires when an error was detected by the computer, An additional type of edit was performed, however, which made changes in the data automatically without the need of looking at questionnaires. Some examples of these types of edit checks are: e All facilities responding to the nursing home questionnaire and indicating that they were responsible for room and board only are out-of-scope of the MFIand were made so. ®Adult penal institutions not owned by a State or the Federal Government were made out-of-scope, i.e., county or munici- pal jails. ®Hospitals and nursing homes with less than the minimum number of beds re- quired for inclusion in the MFI (i.e., six beds for hospitals and three beds for nursing homes) were arbitrarily made out of scope. The final computer editing procedure was to impute all of the key items still unknown. The imputations for unknown items for a facility were based on the available data for the responding facilities on the MFI with the same ownership, type of service, and approximately the same bed size, As an example, to impute an unknown number of employees in a privately owned nursing home with less than 25 beds, a ratio of employees to beds was calculated using the data for all respond- ing privately owned nursing homes with less than 25 beds in the MFI, The value then used as the facility's number of employees was equal to the calculated ratio for all privately owned nursing homes with less than 25 beds times the number of beds in the facility having an unknown number of employees. Thus, if the ratio was 1:4 and a facility had 12 beds but an unknown number of employees, the number of employees was imputed as three (4 x 12). All mechanical imputations were based on such critical items as the number of beds or resi- dents the facilities have. Because of this, the question on number of beds was given particular attention throughout the editing process and a value was never imputed arbitrarily, that is, each facility that had this item imputed received indi- vidual attention, Number of beds maintained was obtained either from other items on the facility's questionnaire, a published list or directory of facilities (such as the AHA Hospitals Guide Issue or the Directory of the American Osteopathic Hospital Association), the 1963 MFI, or by corre- spondence with the State agency responsible for licensure of the facility, In all instances where data were obtained from a source other than the facility itself, the source of the imputed data was coded and kept as part of the data record for the facility. A total of 16,480 imputations were made to the 12 items considered key data, Table B shows the number and percent of missing items and the method of imputing infor- mation. Table C gives the number of imputations made to missing items by each source of the im- puted information, Through the utilization of all these sources of information, it was possible to complete all the key items on the questionnaires, using data that were not only characteristic of these facilities individually but also were accu- rate on an overall statistical basis. Of the seven sources of imputed information, the last two listed intable C need further explana- tion, The major source for addition of inpatient health facilities to the MFI is the Agency Report- ing System (ARS), which is a program for determining on at least an annual basis the names and addresses of all newly established inpatient facilities. "The Agency Reporting System (p. 2) explains the origin and functions of the ARS, When the ARS was used as the basis of imputed infor- mation for the MFI, reference was made to the appropriate facility directory, and the missing information for the facility was entered onto the tape record. Table B. Number and percent of missing items and method of imputing data Total missing Data entered from Machine Bates items clerical sources imputation Missing items possible sutvies Number | Percent Number Percent | Number | Percent Hospital questionnaire Type of service-------- 8,147 | 4,704 58 4,089 50 615 8 Number of physicians and dentists---------- 16,294 2,752 17 1,423 9 1,329 8 Ownership----------c--- 8,147 996 12 996 12 - - Number of beds--------- 8,147 887 11 284 3 603 7 Admissions in 1966----- 8,147 595 7 356 4 239 3 Average length of stay- 8,147 482 6 426 5 56 1 Age limitation--------- 8,147 305 4 212 3 93 1] Nursing home questionnaire Ownership-------=------ 19,141 2,410 13 2,410 13 - - Full-time staff-------- 38,282 581 2 54 - 527 1 Persons receiving care- 19,141 517 3 6 - 511 3 Type of facility------- 19,141 169 1 169 1 - - Number of patients----- 19,141 163 1 27 - 136 1 Services provided------ 153,128 96 1 19 - 77 1 Number of beds--------- 19,141 38 - 38 - - - Other questionnaire Ownership-------coc-ooo 3,298 1,055 32 1,055 32 - - Type of facility------- 3,298 209 6 209 6 - - Full-time staff-------- 3,298 198 6 100 3 98 3 Age limitation--------- 3,298 179 5 133 4 46 1 Number of persons------ 3,298 144 4 144 4 3 - Table C. Number of imputations made to missing items by source of information 1967 | Directory Other ' Total AHA of the items Spiga Machibe eid : of hos- American 1963 on | po By Soh Missing liens missing || pital | Osteopathic | MFI | ques- ? Tous BE od items guide Hospital tion=- Slay issue | Association naire Hospital questionnaire Type of service--------- 4,704 | 3,481 3 580 25 615 Number of physicians and dentists----------- 2,752 | 1,400 1 Si 22 va 1,329 Ownership--------------- 996 289 4 | 506 64 133 _— Number of beds---------- 887 205 3 vb 73 3 603 Admissions in 1966------ 595 331 2 1 21 | 239 Average length of stay-- 482 406 2 18 vw 56 Age limitation---------- 305 188 1 . 23 vos 93 Nursing home questionnaire Ownership----------c---- 2,410 11 2 | 411 1,480 506 cli Full-time staff--------- 581 2 > vow 52 eZee 527 Persons receiving care-- 517 vw . 6 ae 511 Type of facility-------- 169 1 3 55 110 vee Number of patients------ 163 ca a 27 _ 136 Services provided------- 96 vive 1 Hin 18 vibe 77 Number of beds---------- 38 #00 . vive 37 1 : Other questionnaire Ownership--------------- 1,055 320 40 | 519 68 108 coe Type of facility-------- 209 sine Tew vote 146 63 or. Full-time staff--------- 198 9 "e vhs 89 2 98 Age limitation---------- 179 aries 1 pe 127 5 46 Number of persons------- 144 1 me 136 4 3 Machine imputations were made based onthe number of beds or persons, ownership, and type of facility. Ratios were computed for the above classes for various characteristics of the report- ing facilities, These ratios were then applied for each of the missing items. By this method, it was possible to impute numbers that were consistent with the size and type of facility. As can be seen from table B, the ownership question on all three forms was poorly answered and required a large number of imputations, The problem was due tothe respondents making multi- ple entries for this item, in which they not only checked the facility's ownership but alsothe type of agency responsible for its licensure, Multiple entries was also the reason the item concerning type of service on the hospital questionnaire required a large number of impu- tations. Instead of indicating their major service only, the hospitals tended to check all services they offered. These cases were resolved accord- ing to editing rules which took into consideration certain natural groupings and priorities. For example, if several varied types of services were checked the item was coded as ''general," thus encompassing the several varieties checked. (As multiple entries were acceptable in the pretest, this problem had not arisen then.) The item asking for the number of physicians and dentists on the hospital questionnaire was often left blank, accounting for the large number of imputations for this item. Data for some facilities using the nursing home or other questionnaire were obtained from the American Osteopathic Directory in those cases involving convalescent hospitals, extended care facilities, and mental retardation hospitals. Facility Classification Hospitals and "other facilities Each facility on the 1967 MFI is classified by its primary type of service according tothe infor- mation provided on the survey questionnaire, In the case of hospitals and "others, the facilities are !'self-classified," that is, the respondent's answer to the specific question requesting the primary type of service provided in his facility becomes its classification (question 10 on the hospital questionnaire and seven on the "other''). In those cases where the respondent checked nothing or more than one primary type of service, the type selected was determined by examining other data on the questionnaire, such as the facili- ty's name, age and sex of patients, etc., or by consulting various lists and directories of facili- ties such as hospital licensure lists. Nursing and personal care homes The classification of nursing, personal care, and related homes is not so simple, however, since facilities calling themselves nursing homes do not necessarily provide nursing care as their primary type of service, Consequently, a scheme for refining the classification similiar to that used in the 1963 MFIwas adopted inthe 1967 MFI. The scheme made it possible to classify nursing, personal, and domiciliary care homes uniformly into four groups according to the level of care provided to the residents. The four classifications are defined as follows: 1. A nursing care home provides nursing care to 50 percent or more of its residents during the week prior to the day the questionnaire was completed and has at least one registered professional nurse or licensed practical nurse working 35 or more hours per week, Nursing services include nasal feeding, catheteriza- tion, irrigation, oxygen therapy, full bed bath, enema, hypodermic injection, intravenous in- jection, temperature-pulse-respiration, blood 10 pressure, application of dressing or bandage, or bowel and bladder retraining. 2, A personal care home with nursing provides nursing care to some, but less than 50 percent, of the residents or provides nursing care to more than 50 percent of the residents, but has no full-time RN's or LPN's on the staff, 3. A personal care home does not provide nursing care to any residents during the reference week but routinely provides three or more of the six personal services specified on the questionnaire (help with tub bath or shower, dressing, correspondence or shopping, walk- ing or getting about, eating, and the provision of rub and massage). 4, A domiciliary care home provides care prima- rily to residents able to care for themselves. Such a home has an accepted responsibility for the personal well-being of its residents and provides personal services as needed. A domiciliary care home routinely provides one or two of the specified personal services and did not provide nursing care to any of its residents during the week prior to the day the questionnaire was completed, See appendix II for a more detailed description of the classification system. SURVEY EVALUATION Response to the 1967 MFI In any large survey undertaking such as the MFI, it is usually not feasible to obtain a reply from all the respondents or even to verify each one's existence, In the 1967 MFI, for example, 14,828 facilities either did not respond to our several inquiries, were found to be out of scope of the MFI (that is, did not meet the minimum bed size or definitional criteria or were out of business), or the questionnaires were returned by the Post Office as undeliverable for such rea- sons as unknown address, unclaimed, etc., as shown in table D, The duplicates listed in table D were those facilities which were included more than once in the MFI listing and were therefore sent more than Table D. Number and type of unusable questionnaires by type of facility: Master Facil- ity Inventory, August 1967 Type of facility Type of unusable questionnaires : Nursing Total || Hospital don, Other Total-mmmm mmm mmm mm eee em om 14,828 3,487 10,088 1,253 Out of scope Duplicates == === mmm mee ee eee 2,270 699 1.156 415 Didn't meet definitionalcriteria-----=-=ccocemaao-- 5,312 1,678 3,368 266 Out of business------c-mom cmc 4,227 774 3,222 231 Under construction and temporarily out of business- 133 33 64 16 Nonresponse © Questionnaire not returned----------mmmm mcm ecaeaa- 730 90 523 117 Post Office returns Unknown = === = c= cme meee eee eee 751 63 621 67 Unclaimed---===cccmom cmc cme eee eee - 172 10 153 9 Insufficient address-------cccmccccmcm meee 138 22 94 22 [0] 5 T= EE a ata 232 27 173 32 Moved == === = mmm em meee eee emma — 883 91 714 78 one questionnaire, Included in these duplicates were 392 facilities which were either subunits of the responding facility (for example, a unit of a hospital complex located at a separate address), or conversely, a complex of which the responding facility was a part (for example, the adminis- trative office for several nursing homes, each located at a different address). The majority of the 5,312 facilities classified in table D as not meeting the definitional criteria were hospitals’ with less than six beds, "nursing homes" with less than three beds, or facilities that only provided room and board. Questionnaires returned by the Post Office for reasons such as out of business, deceased, or demolished were included with those question- naires returned by the addressees as being no longer in business. Included in the 730 nonre- sponse questionnaires were those that the facility returned to NCHS completely blank, refusals, and those sent to facilities that were never heard from in any manner, Before calculating the response rate, all those fatilities that were included in the MFI mailings but were later identified as .out of scope were deleted. Using the resulting figures as the base, the response rates are 93.5 percent for the MFI in general, 97.4 percent for the hospital portion, 91.8 percent for nursing homes, and 93.8 percent for other facilities, Although a great deal of effort was made to include in the MFI all existing hospitals with six or more beds and resident places with three or more beds, it is reasonable to assume that some proportion of these places, hopefully small, was missed. Those that were missed are those places which for some reason rarely appear on lists of institutions, They are probably marginal places, either in definition or in size. Also missing are those places which were judged tobe out of scope of the MFI because they had fewer than the re- quired number of beds, but which have since ex- panded in bed size. C00 1 APPENDIX | FORMS Form NHS-HRS-4 (H)a (7-27-67) FORM APPROVED BUDGET BUREAU NO. 68-567036 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS FOLLOW-UP INQUIRY Master Facility Inventory Gentlemen: Thank you for returning the Master Facility Inventory questionnaire (Form NHS-HRS-4(H)). Some necessary information, however, was missing from the original form. Please supply the information for the items circled in red on the reverse side of this letter. After entering the necessary information, please return this form in the enclosed envelope which requires no postage. We should appreciate your returning the completed form within three days. Sincerely yours, CL. (Ress Ec talen A. Ross Eckler Director Bureau of the Census Enclosure FOLLOW-UP INQUIRY NOTE — Please complete the item(s) circled in red. 8. Please place an “’X’’ in only ONE box for the type 11. Does your hospital serve: Check only one * of organization operating your hospital. The type of organization legally responsible for the opera- .1 [__] Primarily children (under 21) tion of the hospital. Check only one 11 [| State ™ 2 [| Primarily adults (21 or over) 12 [_] County 3 [_] Both children and adults 13 Cit State—lLocal [JG Government a [| Other age limitation — Spoetfy— 14 [| City — County 15 [| Hospital District 10.8. Public Health Servi 2 13. What is the total number of beds regularly maintained w ublie fea erviee (set up and staffed for use), for inpatients? Armed F . Include beds in subunits of the hospital such as w [1 amied Pores I'ederal nursing home units. Do not include beds used 18 [] Veterans Administration Government exclusively for emergency services and bassinets ! in newborn nursery. 19 [| Other Federal Agency : TT Total beds 20 [| Church related 21 [| Nonprofit corporation Nonprofit 14. What was the average length of patient stay (per 22 [| Other nonprofit discharge) in your hospital during calendar year 19667 23 [Individual 1 [| Less than 30 days 24 [] Partnership For profit 2 al 30 days or more 2s [| Corporation 16. What was the number of inpatient admissions to your . : 2 10. Please read all of the following TYPES OF hospi during golendaryear 19461 SERVICES, then check the term(s) that best Relupe Wewvorn. describes your hospital. [Indicate your major Tm —— service area(s) only. 31 [| General medical and surgical 32 [| Psychiatric 19. Please give the number of full-time and part-time 33 [| Mental deficiency or retardation 3a [| Geriatric 35 [| Tuberculosis 36 [| Orthopedic 37 [| Maternity 38 [| Eye, ear, nose and throat 39 [| Chronic disease a0 [| Epileptic a1 [|] Alcholic a2 [| Narcotic a3 [| Contagious disease aa [| Rehabilitation center as [| Other — Specify treatment wer gy personnel currently ON THE PAYROLL of your hospital. Include all donated services of members of religious orders. Exclude all trainees, private duty nurses and volunteers. (Full-time and part-time are defined below.) Full-ti me Part-time Personnel (35 hrs. or more | (Less than 35 per week) hrs. per week) a. Number of physicians and dentists b. All other c. Total (a plus b) FORM NHS-HRS-4(H)a (7-27-67) 13 Form NHS-HRS-5(N)a (7-27-67) FORM APPROVED BUDGET BUREAU NO. 68-S67035 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS FOLLOW-UP INQUIRY Master Facility Inventory Gentlemen: Thank you for returning the Master Facility Inventory questionnaire (Form NHS-HRS-5(N)). Some necessary information, however, was missing from the original form. Please supply the information for the items circled in red on the reverse side of this letter. After entering the necessary information, please return this form in the enclosed envelope which requires no postage. We should appreciate your returning the completed form within three days. Sincerely yours, Cx (Reso Eo f1len A. Ross Eckler Director Bureau of the Census Enclosure 14 FOLLOW-UP INQUIRY NOTE - Please complete the item(s) circled in red. 6. Please place an “‘X’’ in only ONE box for the type of organization operating your facility. The type of organization legally responsible for the opera- tion of the facility. Check only one 1 [State A 12 [County 13 [1 City 1a [| City — County State—Local Government 1s [| Hospital District et eer Sean) 16 [| U.S. Public Health Service Rh 17 [| Armed Forces Federal gp 7 Government 18 i Veterans Administration ( 19 [1 Other Federal Agency 20 [I Church related 21 [| Nonprofit corporation Nonprofit 22 [__] Other nonprofit 23 [Individual 24 [Partnership For profit 25 Corporation 11. What is the total NUMBER OF PERSONS (patients or residents), who stayed in your facility last night? Do NOT include employees or owners. Number of persons 12. During the past seven days, how many of the PERSONS in question 11 received ‘‘Nursing Care’? Consider that a person received “Nursing Care’’ if he received any of the following services: Nasal feeding Catheterization Irrigation Oxygen therapy Full bed bath Enema Hypodermic injection Intravenous injection Temperature-pulse- respiration Blood pressure Application of dressing or bandage Bowel and bladder retraining Number of persons 7. Please read ALL of the following, then check the ONE term which best describes your facility. Check one only so [| Nursing Home st [|] Convalescent Home s2 [|] Rest Home 53 [| Home for the Aged sa [| Boarding Home for the Aged ss |__| Home for Crippled Children s6 || Home for Needy 57 [| Home for Incurables ss [| Home for the Mentally Retarded s9 [| Other — Please describe — 13. Which of the following services are ROUTINELY provided? Check all that apply. 1 [|] Supervision is provided over medications which may be self-administered 2 | |Medications and treatments are admin- istered in accordance with physicians orders [1 Rub and massage [J Help with tub bath or shower [Help with dressing [J Help with correspondence or shopping [J] Help with walking or getting about [J Help with eating OR 9 [_] Not responsible for providing any services except room and board — (If this box is checked no other box should be checked in question 13.) ® NO un» Ww 10. What is the TOTAL NUMBER OF BEDS regularly maintained for patients or residents? Include all beds set up and staffed for use whether or not they are in use at the present time. Do NOT include beds used by staff or owners and beds used exclusively for emergency services. Total beds 14. What is the total number of full-time personnel on the payroll of this facility? Full-time personnel are those who usually work 35 hours or more per week. Include owners, managers, and members ot religious orders who work full-time whether on the payroll or not. Do not include volunteers, private duty nurses, and part-time employees. TOTAL full-time personnel Of the above personnel, how many are: a. Licensed registered WUTSBE 2 « + 4 + 2 mw s b. Licensed practical or vocational nurses. 15 FoRrRM NHS-HRS-6(0)a (7-27-67) FORM APPROVED BUDGET BUREAU NO. 68-567036 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEAL TH STATISTICS FOLLOW-UP INQUIRY Master Facility Inventory Gentlemen: Thank you for returning the Master Facility Inventory questionnaire (Form NHS-HRS-6(0)). Some necessary information, however, was missing from the original form. Please supply the information for the items circled in red on the reverse side of this letter. After entering the necessary information, please return this form in the enclosed envelope which requires no postage. We should appreciate your returning the completed form within three days. Sincerely yours, Cx (Reso EE trlen A. Ross Eckler Director Bureau of the Census Enclosure 16 FOLLOW-UP INQUIRY NOTE — Please complete the item(s) circled in red. 6. Please place on “‘X"’ in only ONE box for the type of organization operating your facility. The type of organization legally responsible for the opera- tion of the facility. Check only one 11 [ State N 12 CL] County 13 [|] City State—L.ocal Government 1a [| City — County 15 [| Hospital District 16 [J U.S. Public Health Service 17 [__] Armed Forces Federal wo ; Government 18 | Veterans Administration 19 [_! Other Federal Agency SPECT or me coe socom cot mr i 20 [| Church related 21 [| Nonprofit corporation Nonprofit 22 [__] Other nonprofit 23 [Individual 24 [| Partnership For profit 25 ! Corporation 8. Does your facility serve: Check only one + [|] Primarily children (under 21) 2 [|] Primarily adults (21 or over) 3 [_] Both children and adults 4 [_] Other age limitation — Spacifymey 10. What is the total NUMBER OF PERSONS (residents, patients or inmates), who stayed in this facility last night? Do NOT include employees and proprietors. Total persons 11. What is the total number of full-time personnel currently on the payroll of this facility? Full-time ereonmel are those who work 35 hours or more per week. Include owners, managers, and members of religious orders who work full-time whether on the payroll or not. Total full-time personnel 7. Please read ALL of the following, then check the ONE term which best describes your facility. Check one only Sheltered care, custodial care and training facilities 70 [| Home or resident school for deaf 71 [| Home or resident school for blind 74 [| Home for unwed mothers 75 [| Orphanage 76 [| Home for dependent children 77 [| Home or school for physically handicapped 78 [|] Home or resident school for mentally retarded 79 [| Home or resident school for emotionally disturbed 81 [| Other — Describe Correctional facilities 82 [| Training school for juvenile delinquents 83 [_ Detention home, primarily for juvenile delinquents 84 [| Reformatory 8s [| Prison, jail, or penitentiary 86 [| Other correctional facility — Describe FORM NHS-HRsS-6(0)a (7-27-67) 17 FORM NHS-HRS-6(0) FORM APPROVED (6-22 N 67) BUDGET BUREAU NO. 68-S67036 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE ATIONAL CENTER FOR HEALTH STATISTICS MASTER FACILITY INVENTORY Dear Sir: The National Center for Health Statistics (NCHS) of the U.S. Public Health Service is assembling an up-to- date list of all facilities in the United States which provide some kind of medical, nursing, personal, domiciliary or custodial care. This program is being coaducted as a part of the U.S. National Health Survey, authorized by Public Law 652 84th Congress. The Seon of the Census has been requested to act as collecting agent for the NCHS in compiling the list. The purpose of this survey, in which you are being asked to participate, is to obtain current information, such as number of beds, staff size, and types of services provided, from each facility on the list. The information will be used to compile statistics on the number and kinds of such facilities in the United States. Sections A and B of this form request verification of the name and address of the facility, type of service, type of ownership, staff size and capacity. Section C asks for additional information which is needed for detailed statistics on other characteristics of the facility. All information provided in Section C will be accorded confidential treatment by the Bu-eau of the Census and the Public Health Service and the statistics will be presented in such a manner that no individual facility can be identified. For this purpose we are requesting that you complete this questionnaire for your facility and return it within five days in the enclosed postage-paid envelope. The questionnaire is very brief and should take only a few minutes to complete. Thank you for your cooperation. Sincerely yours, A. Ross Eckler Director Bureau of the Census Enclosure Section A — IDENTIFICATION OF FACILITY Please refer to the mailing label above, then make all additions and corrections according to the questions below. Detailed identification information is needed to prevent duplicate listings and to assure that your facility is properly represented in our files. (Please type or print) is the NAME shown in the label above Correct name of facility if different from above correct for your facility? 17] Yes 2] No==Please line through name in label and enter correct name ——————e Other names of your facility Is your facility known by any other NAMES(S)?, 1] Yes—Please give other name(s)——= 2] No Is the address shown in the label above the Number | Street 'P.0. Box, route, etc. I correct mailing address for your facility? ! 1 City or town 107] Yes > 3] Ne a ph Lagos ox County i State ZIP Code correct mailing address. i | Is your mailing address also the ACTUAL Number | Street ® LOCATION of your facility? | 17 Yes City or town 2[C7) No—=Please give complete address for | County | State | ZIP Code actual location of your facility. | ! m Vi Area code | Number What is the telephone number of your facility? | GENERAL INSTRUCTIONS FOR COMPLETING QUESTIONNAIRE a. Include in this report information for the facility named in the mailing label or for its successor if the name or owner has changed. Include information for one facility only, but report for the entire facility including infirmaries and other subunits. b. Due to name and address changes, duplicate listings in our file, or other reasons, you may have been sent more than one questionnaire under different names or addresses. If you receive more than one form for the same facility, complete one only and return all others with the notation ‘‘Completed and returned under . . . (give name of facility on completed form).” c. Answer all questions, please. Definitions and special instructions are given with the questions when needed. d. Return the completed questionnaire in the postage paid envelope provided, to: Jeffersonville Census Operations Office, 1201 East 10th Street, Jeffersonville, Indiana 47130. Section B — CLASSIFICATION INFORMATION Please place an ‘‘X’’ in only ONE box for the type of erganization operating your facility. The type of organization legally responsible for the opera- tion of the facility. Check only one 117] State 12[__| County 13] City 1a[__] City — County 1s[__] Hospital District State—Local Government 16[__] U.S. Public Health Service 17[_] Armed Forces Federdl tia ; Government 18[_] Veterans Administration 19[__] Other Federal Agency SPCCHY oie cs ie ines 20[__] Church related 21[__] Nonprofit corporation Nonprofit 22[__| Other nonprofit 23] Individual 2a] Partnership For profit 2s[__| Corporation Does your facility serve: Check only one 1[] Primarily children (under 21) 2[] Primarily adults (21 or over) 3[] Both children and adults 4[] Other age limitation — Speiilyy 1[] Males only 2[] Females only 3[] Both males and females (10) What is the total NUMBER OF PERSONS (residents, ! patients or inmates), who stayed in this facility last night? Do NOT include employees and proprietors. Total persons —> Please continue with question 11 in Section C. Please read ALL of the following, then check the ONE term which best describes your facility. Check one only Sheltered care, custodial care and training facilities 70[] Home or resident school for deaf 71[_] Home or resident school for blind 74] Home for unwed mothers 75[__] Orphanage 76] Home for dependent children 77] Home or school for physical handicapped 78[] Home or resident school for mentally retarded 79[_] Home or resident school for emotionally disturbed 81] Other Describe Correctional facilities 82[_] Training school for juvenile delinquents 83[_] Detention home, primarily for juvenile delinquents 84] Reformatory 8s[_] Prison, jail, or penitentiary 86[__] Other correctional facility ~DeSOrIDE ow ws we wo i ves ims in Comments 20 Section C — INFORMATION FOR STATISTICAL USE ONLY 0) What is the total number of full-time personnel currently on the payroll of this facility? Full-time personnel are those who work 35 hours or more per week. Include owners, managers, and members of religious orders who work full-time whether on the payroll or not. What is the NAME of the person, corporation, or other organization which owns this facility? Name Total full-time personnel (©) Does this facility maintain a hospital, infirmary or other medical unit? 1] Yes —> Please answer a through § below for that unit. x [] No—> Go to 13 . What type of unit is maintained? 1[] Hospital 2[] Infirmary 3 | Other — Describe —. _ _ — oo oo oe . What type of service is provided in the unit? 1[] Outpatient only 2[] Inpatient only 3[_] Both inpatient and outpatient oo c. Who is responsible for medical care in the unit? Check one only 1] Physician 2[] A registered nurse B[V IOther — BDCUIY me wereen om ot vm moms ton on a. . What is the total number of beds regularly maintained in the unit for inpatients? Total beds . Are the admissions to this unit restricted to the patients, residents, inmates, or employees of this facility? 1] Yes 2[] No . If the name or address for the unit is different than that for the facility, please give the correct name and address below. - Does the owner of this facility own or operate any related or similar facility which is NOT included in this report? For example, another facility of the type listed in question 7, or a hospital, nursing home, or other institution. 1] Yes 2] No—>Go to 15 Please provide the following information for all other facilities owned. Use the “Comments’’ section if additional space is needed, or attach a separate listing when available. Name of facility Type of facility Address - Number and street City State ZIP code (5) Name of person completing this form Name Title Address — Number and street Date City y State TZIP code | 1 COMMENTS — General comments are invited as well as comments on specific items FORM NHS-HRS-5(N) (6-19-67) N FORM APPROVED BUDGET BUREAU NO. 68-S67036 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE ATIONAL CENTER FOR HEALTH STATISTICS MASTER FACILITY INVENTORY Dear Sir: The National Center for Health Statistics (NCHS) of the U.S. Public Health Service is assembling an up-to- date list of all facilities in the United States which provide some kind of medical, nursing, personal, domiciliary or custodial care. This program is being conducted as a part of the U.S. National Health Survey, authorized by Public Law 652, 84th Congress. The Se of the Census has been requested to act as collecting agent for the NCHS in compiling the list. The purpose of this survey, in which you are being asked to participate, is to obtain current information, such as number of beds, staff size, and types of services provided, from each facility on the list. The information will be used to compile statistics on the number and kinds of such facilities in the United States. Sections A and B of this form request verification of the name and address of the facility, type of service, type of ownership, staff size and capacity. Section C asks for additional information which is needed for detailed statistics on other characteristics of the facility. All information provided in Section C will be accorded confidential treatment by the Bureau of the Census and the Public Health Service and the statistics will be presented in such a manner that no individual facility can be identified. For this purpose we are requesting that you complete this questionnaire for your facility and return it within five days in the enclosed postage-paid envelope. The questionnaire is very brief and should take only a few minutes to complete. Thank you for your cooperation. Sincerely yours, L. Ross Colalor: A. Ross Eckler Director Bureau of the Census Enclosure Section A — IDENTIFICATION OF FACILITY Please refer to the mailing label above, then make all additions and corrections according to the questions below. Detailed identification information is needed to prevent duplicate listings and to assure that your facility is properly represented in our files. Please type or print) V's tiie NAME shown inthe. label cbove Correct name of facility if different from above correct for your facility? 12 Yes 2[_] No—=Please line through name in label and enter correct name Is your facility known by any other NAMES(S)? rier memes of you feollity 1 Yes—=Please give other name(s )—— 27 No T I ® Is the address shown in the label above the | “umber ! Strest §2.5- Bow Saga: correct mailing address for your facility? i 1 -—y City or town i | Yes 27” No==Please line through address on T T label and give your entire County : Save 4 ZIP Code correct mailing address. i | Is your mailing address also the ACTUAL Number [Street LOCATION of your facility? ; City or town 107] Yes 2] No—=Please give complete address for [ County | State | ZIP Code 1 actual location of your facility. y ! ‘ a Area code 7 Number What is the telephone number of your facility? \ ! Gs 20 22 GENERAL INSTRUCTIONS FOR COMPLETING QUESTIONNAIRE a. Include in this report information for the facility named in the mailing label or for its successor if the name or owner has changed. Include information for one facility only, but report for the entire facility including infirmaries and other subunits. b. Due to name and address changes, duplicate listings in our file, or other reasons, you may have been sent more than one questionnaire under different names or addresses. If you receive more than one form for the same facility, complete one only and return all others with the notation ‘‘Completed and returned under . . . (give name of facility on completed form).” c. Answer all questions, please. Definitions and special instructions are given with the questions when needed. d. Return the completed questionnaire in the postage paid envelope provided, to: Jeffersonville Census Operations Office, 1201 East 10th Street, Jeffersonville, Indiana 47130. Section 8 — CLASSIFICATION INFORMATION Please place an “‘X"" in only ONE box for the type ™ of organization operating your facility. The type of organization legally responsible for the opera- tion of the facility. Check only one 1] State 12[_] County ww] City 14[-_] City — County State—Local Government 15[__] Hospital District 16[__] U.S. Public Health Service Please read ALL of the following, then check the ONE term which best describes your facility. Check one only so[__] Nursing Home s1[__] Convalescent Home s2[__| Rest Home s3[__| Home for the Aged sa[__] Boarding Home for the Aged ss[__] Home for Crippled Children ss [| Home for Needy s7[__] Home for Incurables se [|] Home for the Mentally Retarded so] Other — Please describe — 17] Armed Forces ® Federal 18] Veterans Administration Government 19[_] Other Federal Agency Specify _ — _ _ _ _ _ 20[__] Church related Does your facility serve: Check only one 1+[__ Primarily children (under 21) 2] Primarily adults (21 or over) 3] Both children and adults 4[_] Other age limitation — Specily—3 21[__] Nonprofit corporation Nonprofit 22[__] Other nonprofit Does your facility serve: 1[] Males only 2[] Females only 3[__] Both males and females Check only one 23[] Individual (10) 2a[__] Partnership For profit 2s[__] Corporation What is the TOTAL NUMBER OF BEDS regularly maintained for patients or residents? Include allbeds set up and staffed for use whether or not they are in use at the present time. Do NOT include beds used by staff or owners and beds used exclusively for emergency services. Total beds Section C — INFORMATION FOR STATISTICAL USE ONLY @® What is the total NUMBER OF PERSONS (patients or residents), who stayed in your facility lastnight? Do NOT include employees or owners. Number of persons : ®@ During the past seven days, how many of the PERSONS in question 11 received “Nursing Care”? Consider that a person received “Nursing Care”’ if he received any of the following services: Nasal feeding Temperature-pulse- Catheterization respiration Irrigation Blood pressure Oxygen therapy Application of dressing Fall bed bath or bandage Enema Bowel and bladder Hypodermic injection retraining Intravenous injection Number of persons Which of the following services are ROUTINELY provided? Check all that apply. 1[_] Supervision is provided over medications which may be self-administered 2[] Medications and treatments are admin- istered in accordance with physicians orders 3[] Rub and massage 4[] Help with tub bath or shower s[] Help with dressing s[_] Help with correspondence or shopping 7[] Help with walking or getting about s[] Help with eating OR o[] Not responsible for providing any services except room and board — (If this box is checked no other box should be checked in question 13.) Section C — INFORMATION FOR STATISTICAL USE ONLY (Continued) 1 What is the total number of full-time personnel on the payroll of this facility? Full-time personnel are those who usually work 35 hours or more per week. Include owners, managers, and members of religious orders who work full-time whether on the payroll or not. Do not include volunteers, private duty nurses, and part-time employees. TOTAL full-time personnel Of the above personnel, how many are: Does the owner of this facility own or operate any related or similar facility providing inpatient services which is NOT included in this report? For example, another facility of the type listed in question 7 or a hospital, or other institution. 1 Yes 2] No—>Go to 17 Please provide the following information for all other facilities owned. Use the ‘‘Comments’’ section if additional space is needed or attach a separate listing when available. a. Licensed registered NUIBES: + =i ¢ + vi « wie b. Livensed practical orf vocational nurses. . What is the NAME of the person, corporation, or other organization which owns this facility? Name Name of facility Type of facility Address - Number and street City State ZIP code @ Name of person completing this form Date Title COMMENTS — General comments are invited as well as comments on specific items. 23 FORM NHS-HRS-4 (H) (6-14-87) FORM APPROVED BUDGET BUREAU NO. 68-S67036 U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE U.S. PUBLIC HEAL TH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS MASTER FACILITY INVENTORY Dear Sir: The National Center for Health Statistics (NCHS) of the U. S. Public Health Service is assembling an up-to-date list of all facilities in the United States which provide some kind of medical, nursing, personal, domiciliary or custodial care. This program is being conducted as a part of the U.S. National Health Survey, authorized by Public Law 652, 84th Congress. The Bureau of the Census has been requestedto act as collecting agent for the NCHS in compiling the list. The purpose of this survey, in which you are being asked to participate, is to obtain current information, such as number of beds, staff size, and types of services provided, from each facility on the list. The information will be used to compile statistics on the number and kinds of such facilities in the United States. Sections A and B of this form request verification of the name and address of the facility, type of service, type of ownership, staff size and capacity. Section C asks for additional information which is needed for detailed statistics on other characteristics of the facility. All information provided in Section C will be accorded confidential treatment by the Bureau of the Census and the Public Health Service and the statistics will be presented in such a manner that no individual facility can be identified. For this purpose we are requesting that you complete this questionnaire for your facility and return it within five days in the enclosed postage-paid envelope. The questionnaire is very brief and should take only a few minutes to complete. Thank you for your cooperation. Sincerely yours, CL. 6Roes Eclater A. Ross Eckler Director Bureau of the Census Enclosure Section A — HOSPITAL IDENTIFICATION Please refer to the mailing label above, then make all additions and corrections according to the questions below. Detailed identification information is needed to prevent duplicate listings and to assure that your hospital is properly represented in our files. (Please type or print) Is the NAME shown in the label above Correct name of hospital if different from above correct for your hospital? 1 "Yes 2 [1 No=Please line through name in label and enter correct NAME —————— @ Is your hospital known by any other NAME(S)? Other names of your hospital 1 [7] Yes—=Please give other name(s) — 2 [JNo P.O. Box, route, etc. r Is the address shown in the label above the Number : Street correct mailing address for your hospital? 1 City or town 1 [7 Yes 2 [] No—=Please line through address on i | label and give your entire Coumy I Sate ! ZIP Code correct mailing address. | | Is your mailing address also the ACTUAL Banner J 5Ra LOCATION of your hospital? ! _— City or town 1 [J Yes 2 [7 No—Please give complete address for 5 County I" State ZIP Code actual location of your hospital. i 1 Number (5) Wht is the telephone number of your hospital? Aeaicots | I | ") GENERAL INSTRUCTIONS FOR COMPLETING QUESTIONNAIRE Please read these instructions before completing Sections B and C. a. HOSPITAL as used in this form refers to homes and institutions for the mentally retarded and other mental facilities, medical units of nonhospital establishments (provided the units have one or more inpatient beds), as well as facilities generally recognized to be hospitals. If this facility is not a hospital please use the “‘Comments’ section on page 4 to describe the facility and the services it offers and return the questionnaire. oo . Include in this report data for your entire hospital and all parts, units, component institutions, etc. However, do not include any component or unit which has its own separate discharge procedures. The latter are to be considered separate facilities and should be reported in question 20. If you are in doubt about any unit, please include the unit and explain in the ““Comments’” section. a . Answer all questions, please. Definitions and special instructions are fives with the question when needed. The reporting period used should be calender year 1966. If another yearly period is used for completing this form, please indicate that period in the ‘‘Comments’ section. a . Due to name and address changes, duplicate listings in our file, or other reasons, you may have been sent more than one questionnaire under different names or addresses. If you receive more than one form for the same hospital, complete one only and return all others with the notation “Completed and returned under . . . (give name of hospital on completed form).” ¥ o . Return the completed questionnaire in the postage-paid envelope provided, to: Jeffersonville Census Operations Office, 1201 East 10th Street, Jeffersonville, Indiana 47130. ; Section B — CLASSIFICATION INFORMATION (6) Is your hospital part of a GROUP OR SYSTEM of (® Is your hospital owned by the same organization hospitals, e.g. medical center, city or nonprofit as indicated in question 8? system? 1 Yes 2[ No 1 [Yes NG w= L l What is the name of the group or system? 2 CJ No Indicate the type of ownership 7 De Is your hospital the health care facility for a larger nonhospital institution? 1[] Yes>Complete b and c. 2 [ | No»Go to 8 Please read all of the following TYPES OF SERVICES, then check the term(s) that best describes your hospital. [Indicate your major service area(s) only, b. What is the name and address of the nonhospital 31] General medical and surgical institution? Name 32 [| Psychiatric Address — Number and street ? 33 [| Mental deficiency or retardation [ey State ee ZIP Code | 3a [| Geriatric | | 1 \ 35 [_] Tuberculosis c. Are the admissions to the hospital usually restricted to residents or employees of the : salves thoped nonhospital institution? 36 [_] Orthopedic 1] Yes 2[] Neo Please place an ‘‘X"’ in only one box for the type of organization operating your hospital. The type of organization legally responsible for the opera- tion of the hospital. Check only one 11] State 12] County 13] City 1a] City — County 1s] 16 [7] U.S. Public Health Service 37 [__] Maternity 3 [| Eye, ear, nose and throat 39 [J Chronic disease a0 [| Epileptic State—Local a1 [| Alcoholic Government a2 Narcotic Hospital Digitiet 43 [|] Contagious disease a4 [| Rehabilitation center 17] Amed Forces Federal 18 | Veterans Administration Bower LY O0kionsfienlly Loney A" 19 [| Other Federal Agency {| ~~ =7777777777777 erm Specify, eee meme O) Does your hospital serve: Check only one wl.) Chosmirselaed os +] Primarily children (under 21) #1 Nemprofié-cospasaion ap 2[] Primarily adults (21 or over) #2[_] Othernonprolis 3 Both children and adults a f— For profit +[] Other age limitation — Specify — z[] Corporation J | eemeee————————————— Section B — CLASSIFICATION INFORMATION (Continued) 1 Does your hospital serve: Check only one 1[__] Males only 2[] Females only 3] Both males and females What was the average length of patient stay (per discharge) in your hospital during calendar year 1966? 1[] Less than 30 days 2[__] 30 days or more What was the average daily patient census in your hospital during calendar year 1966? Exclude newborn What is the total number of beds regularly maintained (set up and staffed for use), for inpatients? Include beds in subunits of the hospital such as Average daily patient census nursing home units. De not include beds used exclusively for emergency services and bassinets in newborn nursery. Total beds What was the number of inpatient admissions to your hospital during calendar year 19667 Exclude newborn. Total admissions O Section C — INFORMATION FOR STATISTICAL USE ONLY Beds in Service Units — Please indicate below the number of inpatient beds regularly set up and staffed for use in each of the ‘service units’’ maintained by your hospital. Report for a designated service if a separate and distinct unit is regularly maintained for the service. Include component institutions, divisions, nursing home units, etc. The total should agree with the total bed count provided in question 13? Please give the number of full-time and part-time one. currently ON THE PAYROLL of your hospital. Include all donated services of members of religious orders. Exclude all trainees, private duty nurses and volunteers. (Full-time and part-time are defined below.) (19) Full-time Part-time Personnel (35 hrs. or more | (Less than 35 per week) |prs. per week) Number of beds Service unit a. Number of physicians ® . Medical surgical (Include intensive care) and dentists Oo . Obstetrical b. All other . Pediatric 0 [= . Psychiatric c. Total (a plus b) Does the owner of your hospital own or operate any . Mental retardation ® @ related or similar facility providing inpatient services which is NOT included in this report? Be . Tuberculosis For example, another hospital, a nursing home, a mental or other resident institution. . Rehabilitation 1] Yes 2[] No»Go to 21 =| or . Chronic disease (Other than above) . Nursing/convalescent Please provide the following information for all other facilities owned. Use the ““Comments’’ section on page 4 if additional . All other space is needed, or attach a separate listing when available. If additional facilities are too numerous . Total beds (Sum of “‘a’’ through “i” should be same as number in question 13) to list, indicate the name and address where a complete list may be obtained. Do any of the ‘‘units’’ reported above have a name other than the name shown for the hospital in questions 1 and 2? 1 Yes 2[ | No=Go to 9 Please give name and type of service for each such unit. Use page 4 for additional units. Name of facility Type of facility Address - Number and street Name City Type State ZIP code @ Name of person completing this form Date Title COMMENTS — General comments are invited as well as comments on specific items. 27 APPENDIX I DEFINITIONS AND CLASSIFICATION PROCEDURES Criteria for Classifying Nursing, Personal or Domiciliary Care Homes The criteria for classifying these types of in- stitutions are based on several factors: (1) the num- ber of persons receiving nursing care during the week prior to the day of the survey (nursing, care is de- fined in ''Definitions of Other Terms"), (2) adminis- tration of medications and treatments in accordance with physician's orders, (3) supervision over medi- cations which may be self-administered, (4) the rou- tine provision of the following criterion personal services: rub and massage, help with tub bath or shower, help with dressing, correspondence, shopping, walking or getting about, and help with eating, and (5) the employment of of registered pro- fessional or licensed practical nurses. On the basis of these factors, four types of establishment were distinguished and are defined as follows: Nursing care home.— An establishmentis a nursing care home if nursing care is the primary and pre- dominant function of the facility. Those meeting the following criteria are classified as nursing care homes in this report: One or more registered nurses or licensed practical nurses were employed, and 50 per- cent or more of the residents received nursing care during the week prior to the survey. Peysonal care home with nursing.— An establish- ment is a personal care home with nursing if personal care is the primary and predominant function of the facility but some nursing care is also provided. If an establishment met either of the following criteria it was classified as a personal care home with nursing: 1. Some but less than 50 percent of the residents received nursing care during the week prior to the survey and there was one or more registered professional or licensed practical nurses on the staff. 2. Some of the residents received nursing care during the week prior to the survey, no reg- istered nurses or licensed practical nurses were on the staff, but one or more of the follow- ing conditions were met: A. Medications and treatments were admin- 28 istered in accordance with physicians’ orders. B. Supervision over self-administered medi- cations was provided. C. Three or more personal services were routinely provided. Personal care home.——An establishment is a per- sonal care home if the primary and predominant function of the facility is personal care, and no resi- dents received nursing care during the week prior to the survey. Places in which one or more of the follow- ing criteria were met are classified as personal care homes in this report whether or not they employed registered nurses or licensed practical nurses. 1. Medications and treatments were administered in accordance with physician's orders, or supervision over medications which may be self-administered was provided. 2. Three or more of the criterion personal serv- ices were routinely provided. Domiciliary care home.— A facility is a domiciliary care home if the primary and predominant function of the facility is domiciliary care but has a responsibility for providing some personal care. If the criteria for a nursing care home or personal care home are not met but one or two of the criterion personal services are routinely provided, the establishment is classified as a domiciliary care home in this report. In the classification process, a criterion was con- sidered as not having been met’if the necessary infor- mation for that criterion was unknown. For instance, if the type of nursing staff was unknown for a particular place, it was considered as not having met the criteria of having one or more registered nurses or licensed practical nurses on the statf. Establishments indicating that some nursing care was provided, but not the num- ber of persons to whom this care was provided, were considered as institutions providing nursing care to some but less than SO percent of their patients or resi- dents. Table I shows in detail the classification of the establishments. Table I. Criteria for classification of establishments Classification variables Classification criteria Percent of total residents who received nursing care during the week prior to day of study . 50 percentor more Some but less than 50 percent None Number of registered or licensed practical nurses 1+ None + None 1+ None Are medications or treatments administer- ed in accordance with physician orders? «oe o| YES No «oo]Yes No Yes No Yes No Is supervision over self-administered med- ications provided? Yes Yes No CE No Yes Are 3+ services offered? No Yes Yes No Yes No Are one or two serv- ices offered? a Yes ro 'Yes| No Yes | No Yes Is room and/or board the only service offered? Yes No | Yes Yes Classification Pn Nursing care home Personal care home with nursing Personal care home Domiciliary care home Legend: Boarding or rooming house (out of scope)-B Definitions of Other Terms Reporting unit.—The term ''reporting unit" refers to the individual units which make up the Master Facility Inventory. The primary objective is to be able to classify places in MFI for any type of hospital or institutional survey that might be undertaken. To accomplish this objective a reporting unit is defined as the smallest organizational unit of an enterprise which provides services to persons whether on a profit or nonprofit basis, which has a separately assigned staff or work force, and which maintains separate books or administrative records. The re- porting unit is usually at a single physical location, but may be composed of several subunits at different loca- tions. In some instances the service provided in a re- porting unit willbe mixed, as, for example, in large psy- chiatric hospitals, which often have special wards for geriatric and tuberculosis patients as well as a general medical and surgical facility for the treat- ment of patients within the institution. Here, however, as with all other types of units in the Master Fa- cility Inventory, the primary consideration for classi- fication is the predominant type of service provided if the reporting unit is composed of persons receiving several types of services. Short-stay and long-stay hospitals. —Hospitals are classified in the Master Facility Inventory in accordance with the average length of stay of patients discharged during the calendar year prior to the survey. A short- stay hospital is one with an average stay of less than 30 days. A long-stay hospital is one with an average length of stay of 30 or more days. Bed.—For hospitals, a bed is defined as one which is regularly maintained (set up and staffed for use). Those used exclusively for emergency services and bassinets for newborn infants are not considered to be beds for the purpose of the Master Facility Inventory. A bed in a nursing home or related facility is de- fined as one set up and regularly maintained for patients or residents. This excludes many beds main- tained for staff and those used exclusively for emer- gency services. Resident or inmate.—For the purpose of the Master Facility Inventory a ''resident' or "inmate" is defined as a person formally admitted to or con- 29 fined in an institution and who slept in the establish- ment "last night," i.e., the night prior to the day that the nature-of-business questionnaire was completed for the establishment. Employee.—An employee is defined as a person paid by the establishment or a working member of a religious order who usually works 15 or more hours a week in the establishment. An owner is an employee if he usually works in the establishment at least 15 hours a week. Nursing care.—For the purpose of classifying homes on the Master Facility Inventory which provide nursing care to residents, nursing care is defined as 000 30 the provision of one or more of the following services: Nasal feeding Catheterization Irrigation Oxygen therapy Full bed bath Enema Hypodermic injection Intravenous injection Temperature-pulse-respiration Blood pressure Application of dressings or bandages Bowel and bladder retraining 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 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 veports,—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 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 tothe 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 divorvce.—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, HSMHA Rockville, Md, 20852 PUBLIC HEALTH SERVICE PUBLICATION NO. 1000- SERIES 1-NO 9 [N37 oP : 3 NCHS £3 ¥ b/ > “7 R150 ENE EE LO RR UE Health and Nutrition Examination Survey United States-1971-1973 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Vital and Health Statistics-Series 1-No. 10a For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 Price 75 cents domestic postpaid or 50 cents GPO Bookstore PROGRAMS AND COLLECTION PROCEDURES Series 1 Number 10a Plan and Operation of the Health and Nutrition Examination Survey United States-1971-1973 A description of a national health and nutrition examination survey of a probability sample of the U.S. population 1-74 years of age: Part A—Development, plan, and operation. Part B—Data collection forms of the survey. DHEW Publication No. (HSM) 73-1310 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration National Center for Health Statistics Rockville, Md. February 1973 NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director EDWARD B. PERRIN, Ph.D., Deputy Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, Ph.D., Assistant Director for Health Statistics Development WALT R. SIMMONS, M.A., Assistant Director for Research and Scientific Development JOHN J. HANLON, M.D., Medical Advisor JAMES E. KELLY, D.D.S., Dental Advisor EDWARD E. MINTY, Executive Officer ALICE HAYWOOD, Information Officer DIVISION OF HEALTH EXAMINATION STATISTICS ARTHUR J. McDOWELL, Director GARRIE J. LOSEE, Deputy Director HENRY W. MILLER, Chief, Operations and Quality Control Branch JEAN ROBERTS, Chief, Medical Statistics Branch SIDNEY ABRAHAM, Chief, Nutritional Statistics Branch COOPERATION OF THE BUREAU OF THE CENSUS In accordance with specifications established by the National Health Survey, the Bureau of the Census, under a contractual agreement, participated in the design and selection of the sample and carried out the first stage of the field interviewing and certain parts of the statistical processing. Vital and Health Statistics-Series 1-No. 10a DHEW Publication No. (HSM) 73-1310 Library of Congress Catalog Card Number 72-600207 PREFACE This report presents a detailed description of the Health and Nutrition Examination Survey (HANES). It is intended primarily to serve as a necessary foundation for understanding and use in conjunction with the substantive findings to be published later in preliminary reports and in Vital and Health Statistics, Series 11, of the National Center for Health Statistics (NCHS). It will also provide background information for succeeding surveys of this nature and serve as a guide or aid to others in the planning of similar health or nutrition surveys. In the planning and operation of HANES, valuable assistance was received from many individuals and groups. Space does not permit the recognition of all who participated in the planning, development, and conduct of the many and varied aspects of the survey. Their assistance is gratefully acknowledged, however, and an apology is offered for those omitted. Mention should be made of the important role played by the U.S. Bureau of the Census. Under a contractual arrangement, the Bureau of the Census participated in certain aspects of the sample selection, in the conduct of initial household interviews, and in most of the processing of the data. The special role of a task force designated to formulate a general plan for HANES and chaired by Mr. Earl Bryant, Office of Statistical Methods, NCHS, is described in the text. Also requiring special mention is the role of the Center for Disease Control (CDC), Health Services and Mental Health Administration. In addition to the advice and assistance provided in the planning operation, particularly by past and present members of the Nutrition Program and by the Division of Laboratories, Dr. David Sencer, Director, CDC, established a Nutrition Laboratory where, under a reimbursable arrangement, essentially all of the laboratory work for the HANES program is carried out in a highly standardized manner under the direction of Dr. Hipolito Nino. The overall responsibility for planning the program was that of Mr. Arthur J. McDowell, Director, Division of Health Examination Statistics (DHES). The primary responsibility for recommending the content of and developing the procedures for the various parts of the detailed component for the examination was that of Dr. Arnold Engel, Medical Advisor for the adult programs of DHES. His counterpart with respect to responsibility for the nutrition component of the examination was Dr. Frank W. Lowenstein, Medical Nutrition Advisor, DHES. Dr. James E. Kelly, Dental Advisor, NCHS, and Dr. Lawrence E. Van Kirk, Jr., Dental Advisor, DHES, had similar responsibilities with respect to the dental component. Other members of the DHES staff who had responsibility in specific areas were Dr. Harold Dupuy, Psycho- logical Advisor, Drs. John V. Federico and Lanie E. Eagleton, formerly Medical Advisors, Miss Jean Roberts, Chief, Medical Statistics Branch, and Mr. Sidney Abraham, Chief, Nutrition Statistics Branch. CONTENTS Part A INITOBMCHON, « « wv 0 2 50 = oo © woe oom rm we we ww www FE we ww Role of the NCHS Task Force . . . . . . . . «i i i i vv vv vue. Chargetothe Task Poree -. «vc sv vs ssw ws me smo ad obs soos BecoMMENGRIIONS + « «+ vw 5 « © 5 v #8 & © =o + w 6 0 5% « x & 5 = wo Background of HES . . . ct v0 ss ss ss 5 sa smn sn sama» 85% 605 Basic Characteristics + + = 6 5 vt 5% 2 Bu 5p ® mm 5h eo a PastHES Programs . o + « « + 2 3 s 395 0 = © 2s so w'= 0 93 0 2.98% 3 Planning for the Health and Nutrition Examination Survey . . ........ ss Lr Development of HANES General Objectives . . . . . ........... Development of Some Specific Areas of the Detailed Component . . . . . Development of Specific Areas of the Nutrition Component . . . . . . .. PUA TESUHAG «on oo 0 40% 250 5 ad 6 6% 5 2 db % 8 5% & & 0» 4 SUMIITEIY oo 5 le % 0 4 5 4 0 5 4 or = 5 2 3 gee 6 ae be eee ae Sample Design . + vv + 9 mv 2 ¥ ¥ 2 BEY MEE KF HE EEE NEE Ea General Plan . . « sc cos sv rs aw s 2 FA sas PrP EE Ba 3 ern s DesignSpecifications . « + + «4 sv scp s a ss a ss db 3 as 0 2 dha ® 48 Stratification and Selection of Primary Sampling Units . . . . .. ... .. Within PSUDECSISN. «+ « + ss s+ ce x5 st ns 2% v #4 v #2 x 2% ¢ © 4 3 Scléctionof Sample Persons « + + « v's srs sy sae sts sibs ow 83 a OtherSampling ASPECtS « + « « + « s + 5 2 vs 3 2s 2 Fas hs a 8 0% 0s +o Sampling Features of the Examination . . ................. Stand Sequencing and Scheduling . . . ........ 000. Advance AITARGEMENTS « « + + « 4 « « & & &# & % 4 5 ¢ & 6 5 0 5 4 6 & % + & % Professional Relations. + « + + # 6 5 = 2s 4 #5 ow wp #0 win 5m no a 3 4b PublicRelZtions . : on #23 599 28 06 # sme ow ome ows ses Logistical Arrangements + « «+ os 2 2 #5 3 am wm 65 5 2% £2 0 0 2 & Household Interviewing Procedures . . . . . . . ............... Census INEIVIEWING +» 2 © « + 5 3 + 5 +s si 8 + F a 5 2% 8 ¢ 6O 8 E ® 580 HANESInterviewing . . « «+ cu ct vm ss a ss 2 5 s 8 5 0% vw 8s 5% % & & Page CONTENTS—Con. Appointment and Transportation Procedures . . . . . ............ Examination Center and Field Staff . . . . .. .. .............. Examination Center Procedures . . . . . ................... General . . x px Fin rm Ey Es pee me mR REE ew FlowofExaminees . . . . «as os 2453 052 ass28vsmssnissoan Physician and Nurse Examination . . ................... Ophthalmology Examination . . . . ........... 0... 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Definition of Tete + « 5 «+ 2 vss 2 1a wv ss spa Bs ss 8 0 38 8 00 Location of the 65 Health and Nutrition Examination Survey StandsbY Region + « wv «cx sss esx a bp 3 Rada a +4 8 $6 & 49 4 vi SYMBOLS Data not available re Category not applicable------soeeeemee eee Quantity zero Quantity more than 0 but less than 0.05----- 0.0 Figure does not meet standards of reliability or precision----------=--sceeememeeeenne % PLAN AND OPERATION OF THE HEALTH AND NUTRITION EXAMINATION SURVEY Henry W. Miller, Division of Health Examination Statistics INTRODUCTION The National Health Survey Act of 1956 provides for the establishment and continuation of a National Health Survey to obtain informa- tion about the health status of the population in the United States, including the services received for or because of health conditions. The respon- sibility for the development and conduct of that program is placed with the National Center for Health Statistics (NCHS), a research-oriented statistical organization within the Health Serv- ices and Mental Health Administration (HSMHA) of the Department of Health, Educa- tion, and Welfare. Three separate and distinct programs are employed by NCHS in meeting the objectives of the Act—a household health inter- view survey, a family of surveys of health resources, and a health examination survey.! Between the passage of the 1956 Act and 1969, numerous studies related to nutrition were conducted by various sources which re- vealed that within certain areas of the United States and within certain age and income groups malnutrition and undernutrition were stark real- ities. The most recently completed of these studies was the National Nutrition Survey authorized by Congress with the stated objective to ‘“.. . determine the prevalence and location of serious hunger and malnutrition and resulting health problems in low income populations in (ten) selected States representing different geographic regions of the U.S. and to make recommendations for dealing with such conditions.” The preliminary results of that survey, the various programs being carried out by a number of Federal agencies to combat domestic hunger and nutrition problems, and the need for data on the magnitude and distributions of these problems in the total U.S. population prompted the Department of Health, Education, and Welfare in 1969 to establish a continuing na- tional nutrition surveillance system under the authority of the 1956 Act for the purposes of measuring the nutritional status of the U.S. population and monitoring the changes over time. The task of developing a plan to carry out the new program was assigned to NCHS. ROLE OF THE NCHS TASK FORCE Charge to the Task Force A task force was selected by NCHS of staff members representing a variety of disciplines to formulate a scientifically sound plan to collect, analyze, and disseminate the data required by the Department. The charge to the task force was to develop a plan specifically to attain the following goals: “1. The development and implementation of a survey design which will permit the use of health data as an objective test of programs to improve nutritional status.” “2. A continuing monitoring of national nutritional status and related health problems so that the evaluation of trends and progress over time will be possible and so that we will have a better basis for allocation of scarce program resources.’ The task force sought the advice of adminis- trators of programs related to nutrition and of practicing nutritionists on specific topics vital to the efficient design of a plan to attain these goals. A work paper developed by members of the task force which posed specific questions and also proposed alternative logistical approaches in implementing the survey was submitted to experts in the field of nutrition. Circulation of the work paper to the Regional Medical Program Services Advisory Committee on Nutrition and Health and to the Inter- government-Agency Advisory Panel for the Na- tional Nutrition Surveillance System elicited a variety of responses; interested individuals who attended The White House Conference on Food, Nutrition, and Health also submitted their opinions. The experts concluded that nutritional status could not be measured and interpreted by a few simple indexes; -a person’s nutritional status is a complex interrelationship of clinical observa- tions, biochemical assessments, anthropometric measurements, sociological and psychological evaluations, and dietary intake or patterns. Hence the modus operandi employed to measure nutritional status would require a staff of highly trained professional teams and operating condi- tions conducive to accurate scientific measure- ment procedures. Opinions on the specific tests required and procedures to be followed varied among the consultants, but the sentiment pre- vailed that standard measurements and proce- dures should be developed and maintained and that continual efforts should be made to im- prove techniques and the overall quality of the data. Some differences of opinion arose concerning whether nutritional status should be estimated for the entire population or, alternatively, for only those segments that are considered to have high risk of poor nutrition. Two major reasons for measuring the whole population’s nutritional status are (1) that a lack of knowledge presently exists concerning the nature and magnitude of nutritional problems in the various segments of the U.S. population; and (2) that a base must be established with which to compare specific segments of the population to determine if a group is relatively disadvantaged and/or in need of special programs. This concept of relative advantage or disadvantage is important within and between time periods. The consultants stressed that although plans should be made to measure the nutritional status of the whole population special attention should be focused on high-risk groups such as preschool children, women of childbearing ages, pregnant and lactating women, the aged, and the low- income group in general. Recommendations The principal points and recommendations of the plan developed by the task force which were approved by the Department and later imple- mented in whole or in part in the survey were as follows: “1. The National Nutrition Surveillance Survey (NNSS) will be a continuing national probability sample survey to provide baseline distributional and trend data on the nutritional status of the one year ‘of age and over, noninstitutional population of the United States, empha- sizing those segments of the population classified as at or below the poverty level, and, to the extent possible, consistent with resources and sample design limitations, women of childbearing ages, pre-school and young school children, and the aged. Special emphasis implies that these groups will be sampled at rates substantially higher than their proportionate representation in the general population. This survey will produce national estimates on the nature and magnitude of nutritional problems in the specified population; for some groups, estimates would be available for broad geographic regions. The national data will provide planners at the national level with a rational basis for allocating scarce resources among the programs designed to combat nutritional deficiencies and related health problems. Trend information available from the survey will indicate the degree to which national goals are met. A survey of this nature will also produce data that relate general health and nutritional variables making it possible to study relationships between certain health conditions such as obesity, atherosclerosis, and dental caries, on the one hand, and measurements of nutritional status, on the other.” “2. The Department had proposed that the NNSS be established under the authority of the National Health Survey Act of 1956. For this and for other reasons, the task force recommended that it “be made an integral part of the National Health Survey Program through £ amalgamation with the existing Health Examination Survey (HES). The interrelationship of nutrition and health strongly suggests that the objectives of the two surveys are similar and compatible. The operational advantages associated with the amalgamation make this choice of instrument logical . . .” “3. The health survey formed by the amalgamation of the HES and the NNSS will incorporate the general objec- tives of the HES, with the objective of the NNSS to estimate the nutritional status of the noninstitutional, civilian, one year of age and over, U.S. population. During the first cycle of the combined surveys, the objective of the HES program, Cycle IV, is to identify health care needs of the adult population of the U.S. as perceived by the HES sample subjects and as scien- tifically determined by specified examinations of selected body systems, and to relate both of these to the health care actually received. The NNSS measurement of nutritional status will consist of a clinical assessment by a physician, a number of biochemical tests on blood and (perhaps) urine, anthropometric measurements, and other measures of nutritional status. ...” “4. The HES-NNSS will be a continuing national probability sample survey with a two year cycle consisting of two annual rounds. That is, each annual sample would be representative of the population and additive to other annual samples. The sample selection procedure will be designed to ensure that the low income population is sampled at a rate several times its proportionate repre- sentation in the general U.S. population. . ..” “5. The combined survey will employ four mobile examina- tion centers staffed by specially trained teams of examiners including physicians, nurses, dentists, nutri- tionists, and technicians. HES headquarters staff, appro- priately supplemented for the new program, will provide expertise on nutritional and medical evaluation and planning. ...” In addition to the preceding items, the task force also recommended the collection of cer- tain data through questionnaires: a household questionnaire to obtain general demographic data, a general medical history questionnaire, and a food programs questionnaire to identify families and specific family members who par- ticipate in food assistance programs. BACKGROUND OF HES Basic Characteristics As stated previously, the Health Examination Survey (HES) is one of the three different programs employed by NCHS to accomplish the objectives of the National Health Survey. It collects data by drawing samples of the civilian, noninstitutionalized population of the United States and, by means of medical and dental examinations and various tests and measure- ments, undertakes to characterize the popula- tion under study. This is the most accurate way to obtain definite diagnostic data on the prev- alence of certain medically defined illnesses. It is the only way to obtain information on unrecog- nized and undiagnosed conditions—in some cases, even nonsymptomatic conditions. It is also the only way to obtain distributions of the population by a variety of physical, physio- logical, and psychological measurements. In addition to the data collected by the examining, measuring, and testing procedures, a wide range of other data are collected concern- ing each of the sample persons examined. Therefore, it is not only possible to study the many potential relationships of the examination findings to one another but also to investigate the relationships of the examination findings to demographic or socioeconomic factors. Any information obtained from the survey that permits the identification of an examinee is held in strict confidence and, with the exception of clinical and other examination findings that the examinee authorizes to be sent to his physician, dentist, or other source of medical care, is used only by persons engaged in the survey for the purposes of the survey. The overall plan of the Health Examination Survey has been to conduct successive, separate. programs in specific age segments of the civilian, noninstitutionalized U.S. population by 1 means of medical and dental examinations, tests, ar 5, and measurements. These. successive programs, re- ferred to as cycles,” have had a specific age segment for the target population and have been concerned with certain specified health aspects of that subpopulation. All HES cycles have made use of a nationwide probability sample of the population. This method makes it possible to obtain the desired information efficiently and in such a manner that the statistical reliability of results is deter- minable. These factors, together with the fact that the examination and measurement proc- esses are highly standardized and closely con- trolled, enable the results of the surveys to describe the entire population of the United States on the basis of relatively small samples. The approach to each cycle has been neces- sarily multidisciplinary in nature. Each has drawn on and combined the talents of statisti- cians, physicians of various specialties, dentists, psychologists, nurses, educators, sociologists, management specialists, and others. In addition, each cycle has involved interagency collabora- tion: The U.S. Bureau of the Census has participated in several phases of the surveys; and other Federal agencies (such as the National Institutes of Health, the Office of Education, and the Children’s Bureau) as well as non- Government agencies (such as schools of public health, medical research centers, and survey research agencies) have also advised and assisted the surveys. The data collected are from national samples of the civilian, noninstitutionalized population. The size of the sample permits some analysis of the data by broad geographic region, population density groups, or other major subgroups of the total sample, but it does not permit analysis by smaller_breakdowns, such as by State. The data are ‘analyzed and the findings are made available to interested persons primarily through the publication of reports prepared in a form usable by large numbers of consumers of health statis- tics. The reports are limited to objective, scien- tific presentation of the particular findings, including estimated levels of prevalence and relevant discussion of various observed relation- ships. They do not include discussion of pro- gram implications of the findings, nor do they present value judgments concerning their impli- cations to public health. The principal reports are published by the National Center for Health Statistics in Vital and Health Statistics, Series 2 and 11. Past HES Programs During the period from 1959 to 1970, three separate survey programs or cycles were con- ducted. Cycle I, conducted between November 1959 and December 1962, was directed toward the civilian, noninstitutionalized U.S. population between the ages of 18 and 79 years, inclusive. The examination was focused on certain chronic diseases, cardiovascular diseases, arthritis and rheumatism, and diabetes. Also included were a dental examination, tests for visual and auditory acuity, X-rays, electrocardiographic tracings, blood chemistry tests, and numerous body measurements. The sample size of Cycle was 7,710 persons, of which 6,672 (86.5 percent) were examined. Details of the plan of that program are described in an earlier report. Reports of various methodological studies3-11 and of the findings!24? are also available. The target population of the second cycle of the HES consisted of children aged 6 through 11 years. That cycle became operational in July 1963 and was concluded in December 1965. The examination was focused primarily on various parameters of growth and development, but it also screened for heart disease, congenital abnor- malities, ENT abnormalities, and neuromusculo- skeletal abnormalities. The size of the sample was 7,417, of which 7,119 (96.0 percent) were examined. A detailed report of the plan, opera- tion, and response results of that cycle? as well as several methodological reports51%6 and re- ports of findings37-8! have been published. The third cycle, conducted between March 1966 and March 1970, was concerned with youths 12-17 years of age, inclusive. As in Cycle II, the focus was on growth and develop- ment. A unique feature of the survey was that the same sample areas and housing units of Cycle II were used again. Thus, many of the Cycle II sample children were also examined in Cycle III, providing valuable longitudinal data. Of the total sample size of 7,518 youths, 6,773 (90.1 percent) were examined. Of those exam- ined, 2,271 were examined in both cycles. A report of the plan and operation of that cycle82 and several methodological reports83-85 have been published. Reports of the findings are becoming available and will increase rapidly now that initial analyses of the data from the second _ cycle are virtually Completed. PLANNING FOR THE HEALTH AND NUTRITION EXAMINATION SURVEY General The decision to amalgamate HES and NNSS into one dual-purpose survey and to distinguish it from the previous HES cycle concept led to its informal renaming as the Health and Nutrition Examination Survey (HANES). The planning for the two components of HANES did not occur simultaneously, although obviously in the later stages the two pieces had to be merged into a single workable plan. Prior to the development or suggestion that the HES program be respon- sible for carrying out a nutrition survey, prelimi- nary planning had already begun for HES Cycle IV. It can be judged from the beginning and concluding dates of the three HES cycles dis- cussed in the preceding section that the opera- tion of HES has had to proceed simultaneously on three different levels—planning, collection, and analysis. There are a number of reasons for this three-level concept of operation, but a principal one is to avoid complete dismantling and re- building of the field organization between exam- ining phases of successive cycles. It also avoids the loss of highly trained field and headquarters personnel whose skills are unique and difficult to replace. Thus, while data were being collected in HES Cycle III, analysis was being made of Cycle II data. At the same time, plans and preparation were being made for Cycle IV, so that upon completion of Cycle III, data collec- tion could begin immediately in the new cycle. The planning which had taken place for Cycle IV came to center around the problems of current and unmet health care needs of the U. S. ‘adult population in response to the widespread interest in that aspect of health services. The target population was to be adults, with heavier sampling of older persons and ‘minority groups. Although Cycle I had also studied a sample of adults, it was planned that the content would include some major areas of interest not in- cluded in the earlier cycle. Areas under consider- ation were diseases of the pulmonary and urinary systems, thyroid diseases, dermatology, determination of bone mineral density, various antibody levels, tests of psychological func- tioning, and additional blood chemistries. Repe- tition of certain Cycle I examination procedures using modified techniques and obtaining addi- tional specific data was also considered; for example, data on hearing as a byproduct of a speech discrimination test, data on the cardio- vascular system obtained by electrocardiograms recorded directly onto magnetic tape, newer methods for obtaining blood pressures, and data on vision from the measurement of intraocular tension and from testing with lenses for acuity correction. Development of HANES General Objectives The specifications around which the general objectives of HANES were developed were based primarily upon the principal points and recom- mendations of the NCHS task force with some modifications, as follows: 1. Each cycle of HANES would cover ap- proximately a 2-year period based on a sample of about 30,000 persons _ aged 1 through 74 years. (Recommendations of the task force had been for the age range 2-84 years; however, because of the prob- lem of response associated with the age group 75-84 years and the expected small number of such persons that would fall into the sample, the upper limit was reduced to 74 years.) 2. All sample persons would receive a specifi- cally designed nutrition examination, with a one-fifth _subsample ¢ of those aged 25-74 years also receiving a more detailed exami- nation based upon the HES component. 3. The sample ‘would be more heavily weighted on the low-income groups, the older age groups, preschool children, and women of childbearing : age. « 4. Three mobile examination centers would be used. (This number was reduced from that of an earlier plan for four for budget- ary reasons.) 5. The examination time for persons receiv- ing the nutrition examination should be under 2 hours; for persons receiving the detailed examination, under 4 hours. 6. The nutrition component would consist of a general physical examination; dermato- logical, ophthalmological, and dental exam- inations; body measurements; biochemical assessments; and dietary intake measures. 7. The HES (detailed) component would carry out the general objectives of HES, with emphasis on health care needs. The data collection period would encompass two HANES cycles because of a smaller yield of examinees due to subsampling. 8. Demographic, health history, health care needs, and dietary data and data on participation in food programs would be obtained through the use of question- naires. Development of Some Specific Areas of the Detailed Component As stated earlier, much of the preliminary planning for the detailed component had already been performed in preparing for HES Cycle IV. It was decided that the central purpose should remain as planned—to obtain data concerning the current and unmet health care needs of persons in the age group 25-74 years. It was considered that these data could best be ob- tained by ascertaining the health needs as self-perceived by the individuals examined, and as professionally and scientifically determined by the survey’s examination and tests. Informa- tion obtained through the use of questionnaires would include data on what health care has been received; and even though the examination would provide some indications of the health care needed, it would not identify specifically the entire range of unmet medical needs. Besides identifying health needs, some account would be taken of the importance of these needs by considering what effect they have had or will have on the individual’s functioning. The result- ant data on health needs would provide an enormous amount of information, heretofore unavailable, that could be studied in relation to the health care that had been, is being, or should be received. It would not, however, provide any ~~ total systems-analysis-type assessment of the present overall functioning of the medical care system. It was recognized that the detailed examina- tion component could not cover all aspects of an individual’s health. The approach used was to select a number of index conditions that could be targets of a single, time-limited examination and that could be related to the symptoms and individually felt health needs of the sample person. These target conditions were chosen to provide needed prevalence information on con- ditions related to some of the commonest symptoms experienced by patients. Thus, the interview and questionnaire data would yield information concerning the sample person’s experiencing the following seven sets of symp- toms or complaints: shortness of breath, joint pain, chest pain, skin problems, dental diffi- culties, trouble with hearing, and visual disturb- ance. In addition, the sample person would be asked about any other kinds of symptoms, complaints, or health troubles he may have. Through the detailed examination it would be possible to establish the presence of chronic pulmonary disease; chronic disabling arthritis of the hip, knee, and other joints; specific derma- tological disease; dental and oral conditions; cardiovascular disease (including peripheral vas- cular disease); thyroid abnormality; auditory acuity; correctable level of visual acuity; as well as the presence of ocular hypertension and other ocular conditions. The above concept is dis- played as providing the information to enter the cells of the matrix shown in figure 1. As a result of having to reshape the detailed component for HANES, it was necessary to drop certain elements planned for HES Cycle IV. The most important of these elements was the . almost total elimination from the first HANES program of any significant separate psycholog- ical examination. It was decided to proceed with further developmental work in this area over the Health needs from HANES examination and test a b ¢ Self-perceived needs and action Pathology | Pathology No athol noted but found, p no treatment | treatment needed indicated 1. No problem or relevant complaint VV Vv X 2. Condition not seen as needing : 7 Vv Vv X any medical attention 3. Condition seen as needing medical ” attention but not under treatment 4. Condition under treatment by J v M.D.,D.D.S., etc. NOTE: Index conditions for the matrix.—Cardiovascular KEY: disease; chronic respiratory disease; disabling arthritis of hip, back, knee; dental and oral conditions; dermatological disease; N) = No unmet need ophthalmologic conditions (including visual acuity); hearing loss; X = Unmet need psychological problem. Figure 1. Conceptualization of the Health and Nutrition Exam- ination Survey approach to measurement of unmet health needs. next 2 years in order to carry out necessary validation, calibration, and developmental work on the full battery of instruments developed by the psychological advisor and on other possible modifications of a psychological battery. In this work it was planned to collaborate with persons in the National Institute of Mental Health and with selected outside experts. One instrument, developed from a small portion of the proposed battery, was to be used in HANES. The final form developed for use in the detailed portion of the survey was the General Well-Being Question- naire. The questionnaire is intended to fill several purposes: to serve as an indicator of overall adjustment; to provide subscales of adjustment, such as emotional stability and control, depressive mood, worry or concern about health, and tension; to collect information on psychological’services needed and prevalence of use of some services; and to serve as a “moderator variable’ or control in the statistical assessment of unmet medical needs. Considerable interest in further national and regional information on hearing sensitivity to pure tone and to speech among adults had been indicated by the staffs of the National Institute of Neurological Diseases and Stroke (NINDS) and the National Bureau of Standards, by members of the American Academy of Ophthal- mology and Otolaryngology, and by other experts in related fields. Data were needed in the development of standards for bone conduction thresholds and for more precise determination of the relationship of bone to air-conduction thresholds and to speech discrimination. These would provide a more valid base or normal standard than is now available for use in the diagnosis of specific conditions and for assessing the functional implication of hearing impair- ment. It was later decided, however, that the speech-testing portion be postponed until the second HANES program because of difficulties in preparing a reliable, valid test on tape that could be administered within certain allowable time limits of the examination and because necessary pretesting requirements could not be satisfactorily completed in time for implementa- tion into the first HANES program. In planning the specific components of the audiometry testing, including the instrumenta- tion and methods to be used, the following experts were consulted individually and in ad hoc meetings: Dr. Eldon L. Eagles, Associate Director, NINDS; Dr. Hallowell Davis, Central Institute for the Deaf; Dr. Ralph Naunton and Dr. Stanley Zerlin, University of Chicago; Dr. John W. Black, Ohio State University; Dr. Paul LaBenz, NINDS; Dr. Leo Doerfler, University of Pittsburgh; Dr. Edith L. R. Corliss and Mrs. Pearl Weissler, National Bureau of Standards; Dr. Hayes Newby and Dr. Donald Causey, Univer- sity of Maryland; Dr. Sadanand Singh, Howard University; and Mr. Kenneth Stewart, University of Pittsburgh. A specific protocol for air- and bone- conduction testing for use in the survey was developed by Dr. LaBenz, who also advised on all aspects of this part of the examination and trained the audiometric technicians. Initial train- ing of the HANES examiners was given by Dr. Mark Doudna, University of Maryland. The field protocol related to the instrumentation and acoustical environment, including the weekly field calibration of the instrument used, the monthly environmental noise surveys, and the daily physical checks of the instruments, was developed by Mr. Kenneth Stewart, in charge of the Acoustics Laboratories, University of Pitts- burgh, who also advised on all related aspects during the survey. The vision examination of adults in HES Cycle I had consisted of testing with and without glasses for near and distance visual acuity. In addition, there had been a limited funduscopic. examination of the eyes, but pri- marily for the determination of hypertension. In the planning for HES Cycle IV, it was recom- mended that a glaucoma screening procedure, probably involving tonometry (Schi$tz-Sklar) and visual field testing, be added to the examina- tion. With the increased interest in more defini- tive information on visual problems and eye conditions among the general population, how- ever, Dr. Carl Kupfer, Director, National Eye Institute (NEI), proposed collaboration and pro- vision for logistical and technical backing for a much more ambitious program. NEI was partic- ularly interested in determining the prevalence and distribution of specific eye diseases and related conditions throughout the United States for use in setting goals and priorities for future emphasis in the field of ophthalmology. Consist- ent with the overall objectives of the survey, an evaluation of treatment needs was incorporated into the examination. Two ophthalmologists from NEI, Drs. James P. Ganley and Arthur F. Garcia, developed the examination form and standardized protocol for the ophthalmic examination and were respon- sible for training and recruiting the examining ophthalmologists. The main impetus for inclusion of an exten- sive dermatology component for HES Cycle IV came from within the profession itself through the National Program for Dermatology. The examination protocol, including an assessment of treatment needs, was worked out by Dr. Marie-Louise Johnson, Division of Dermatology, Dartmouth Medical School, and Director of the Data Collection Unit for the National Program. She also assumed responsibility for recruiting and training the examining dermatologists re- quired to carry out this highly specialized part of the examination. Because of the considerable interest expressed by representatives of the American Heart Asso- ciation, the National Heart and Lung Institute, several areas of the Health Services and Mental Health Administration, and others, it was deter- mined that Cycle IV should include plans to obtain data for the determination of the total prevalence and the distribution of cardiovascular disease, primarily hypertension and heart disease. Although collection of such data had been a major part of the Cycle I adult survey program, it was felt that there was a need for further and more up-to-date information in this area, particularly with respect to the extent of need for medical care and normative electro- cardiographic data. The Cycle I survey of adults did not include an evaluation of pulmonary function. Since chronic pulmonary disease is second only to heart disease as a cause of disability in the adult population, it was recommended that the prev- alence and distribution of this disease be deter- mined. For this purpose, a large battery of tests was considered originally in the Cycle IV plan- ning. Tests considered included spirometry, single-breath carbon monoxide tests for pulmo- nary diffusion, PA and lateral X-rays of the chest to determine lung volume by a planimeter method, the body box or plethysmograph, and an oscillatory method of determining respiratory resistance. In the pilot work on these various tests, it was determined that the body box and the oscillatory method were unsuitable under the operational conditions of the survey. Specific body-size measurements were to be included for a variety of reasons: the measure- ments would provide a minimum of information to be compared with some similar measurements taken in Cycle I, height and weight data to be related to pulmonary function, and other meas- urements to correlate with joint disease. The arthritis examination of Cycle I had included determinations of the prevalence of rheumatoid arthritis and osteoarthritis based primarily on X-rays of the hands and feet. It was decided in the Cycle IV planning that, in keeping with the overall objectives, more empha- sis should be placed on the determination of the amount of disability and on evaluating the medical care that had been received or was needed. Arthritis of the hip, knee, and lower back was to be stressed since they are the cause of much disability from this disease. Two X-rays were to be taken, one of the hips and sacroiliac region, and the other of the knees. In addition, the range of motion of the hips and knees was to be determined by using goniometers. Develop- mental work was performed to determine the necessary modifications of X-ray equipment and settings required to produce the proper quality of hip X-ray for a measurement of leg length at 6 feet instead of the usual 3 feet. This measure- ment was to be obtained to provide more information on its relationship to unilateral osteoarthritis of the hip and the possible allevia- tion of disability from this condition. Much of the work in the development of an arthritis history and of the content of the examination was performed in collaboration with Dr. John Decker, Chief, Arthritis and Rheumatism Branch, National Institute of Arthritis and Metabolic Diseases (NIAMD). Osteoporosis, a fairly common condition, especially in postmenopausal women, was one of the other skeletal conditions considered for inclusion in Cycle IV. The initial choice for measuring bone density was the photon absorp- tion method of Cameron. This method, although quite accurate, required the use of a radio- isotope as a radiation source. After thorough investigation, however, it was found that arrangements for State and national licensing for radioisotopes posed extremely difficult barriers to the use of this method. On the recommenda- tion of Dr. G. Donald Whedon, Director, NIAMD, it was decided to use X-ray densi- tometry instead. The X-ray to be used was one of the hand-wrist with the density determined on the fifth finger and the radius. A contract was arranged with Dr. George Vose of Texas Woman’s University to process the X-ray films. Bone density was to be determined by a microdensitometer coupled to a computer. Previous cycles had included some bio- chemical and hematological determinations, e.g., cholesterol, uric acid, protein-bound iodine, hemoglobin, and serologic tests for syphilis. The final selection of all tests to be included in the detailed component of the examination was not made until the tests required for the nutrition component had been considered since many of the tests could serve both. In the selection of tests for the total HANES, a large number of individual hematologists, biochemists, nutritionists, and clinical pathol- ogists were consulted. Particularly involved were the committee of clinical pathologists of the National Academy of Sciences and the labora- tory division of the Center for Disease Control (CDC). The final selection of tests to be in- cluded in HANES was based not only upon meeting the requirements of the two compo- nents but also upon other criteria. These criteria were that the test be in .general widespread use, adaptable to shipping over long distances, that the number of abnormal values expected in a general population would not be extremely small, and that a period of fasting would not be required before taking a sample of blood from the examinee. Some recommended tests that met the above criteria, such as tests for immuno- globulins, had to be eliminated because of cost. The hematological determinations finally decided upon for all sample persons were hema- tocrit, hemoglobin, red cell count, white cell count, and sedimentation rate. The nutritional biochemistry component would be performed on appropriate specimens of serum or plasma and would consist of determinations for vita- mins A and C, magnesium, serum iron, iron- binding capacity, serum folates, total protein Lr and albumin, and cholesterol. In addition, further biochemical determinations were to be made on blood samples from examinees in the detailed component. These were: total bilirubin, SGOT, alkaline phosphatase, uric acid, calcium, phosphorus, a T-3 index by resin uptake, a T-4 by column, and serum antibody titers for polio I, II, and III, measles, rubella, diphtheria, teta- nus, and amebiasis. Also, a differential white cell count was to be made on blood smears of detailed examinees. In addition to providing advice and assistance in the planning operation, the CDC, Dr. David Sencer, Director, established a Nutrition Lab- oratory where, under a reimbursable arrange- ment, essentially all the HANES laboratory work would be performed. CDC was also instru- mental in developing procedures for obtaining and shipping the specimens and quality control procedures to be used in the field. A casual urine specimen for testing pH, albumin, glucose, and hematuria using reagent strips was included in Cycle IV plans. The same specimen would be acidified, frozen, and sent to CDC for determinations of creatinine, thiamine, riboflavin, and iodine. The last three would be related to creatinine (thiamine per gram of creatinine). In addition, collection of a timed urine specimen was seriously considered for the purpose of a creatinine clearance test, but later pilot work demonstrated that this procedure was too difficult to administer in conjunction with other parts of the proposed examination. Examples of other procedures that had been considered for inclusion in Cycle IV but that were not finally included in later pilot testing were the use of a special X-ray procedure to demonstrate coronary artery calcification, ballis- tocardiogram for evaluating cardiac function, use of ultrasound to determine liver size, semi- automated procedures for taking blood pressure, and the use of tonography for glaucoma evalua- tion. Factors such as cost and difficulty of adaptation to field operation, including time for administration and stage of development among other considerations, were instrumental in their exclusion. In keeping with the overall objective of HES Cycle IV, health care needs, it was planned to include in the dental examination an assessment of the needs for dental care. The assessment was to be accomplished by having the examining dentist apply his clinical judgment above the customary index assessments of oral health and arrive at an estimate of unmet treatment needs. A large portion of the proposed dental examina- tion would also provide data for comparison with that of Cycle I. A final phase of planning for the dental examination resulted in the inclusion of an enamel biopsy procedure. This newly developed procedure is a simple and rapid technique for removing a microscopic layer of enamel from a small area of a tooth for laboratory analysis for fluoride content. The result expressed in parts per million serves as an estimate of the individ- ual’s exposure to and absorption of fluoride. Besides the obvious interest in this finding from the large national sample, comparisons will be made with the number of cavities and fillings on selected surfaces where it is thought that fluo- ride has its most striking impact. — Early plans for HES Cycle IV led to construc- tion of a rather detailed medical history ques- tionnaire that was to be complemented by seven supplements designed to elicit additional infor- mation on positive responses related to certain target chronic diseases. With the inclusion of the nutrition component, drastic cuts in both the number and size of the questionnaires produced a package that consisted of the Medical History Questionnaire, ages 12-74, and the General Medi- cal History Supplement, ages 25-74, to be com- pleted by all of the detailed examination subset of sample persons, along with a possible three supplements—Supplement A, Arthritis; Supple- ment B, Respiratory; and Supplement C, Cardio- vascular—to be completed _only as indicated by posi response to screening questions on the a were the result of extremely widespread consultation in connection with the planning of the content of the detailed examination. They drew extensively on the experience of other surveys including, for example, the respiratory studies carried out by the British Council on Medical Research. Specific advice on matters of direct concern to them came from a number of institutes within the National Institutes of Health (e.g., NIAMD), from various outside professional groups, and from some individual experts in the areas. The development and 10 consultation work was carried out largely by the medical staff within the advisory group of the Division of Health Examination Statistics (DHES). The Health Care Needs Questionnaire was also constructed to obtain information on the individual’s perception of his own health care needs along with information concerning actions related to obtaining health care. Medical advisors within DHES worked closely with experts at the School of Public Health at Johns Hopkins University Medical School in developing the questionnaire. Consultation with staff members of the Medical Sciences Division of the National Academy of Sciences-National Research Council provided corroboration of the approach used. Members of other divisions within NCHS, notably the Health Interview Statistics Division and the Health Resources Statistics Division, were very a in advising on questionnaire wording. Cycle IV had to un ergo very little change except for the addition of several questions regarding housing facilities. This questionnaire, which was developed jointly by members of the DHES staff and the Bureau of the Census i ‘sample a “and yen serves in the final stage of sample : selection. In addition to infor- mation on the age, race, , and sex of all household members, a variety of other data is obtained— family income, marital status, ethnic back- ground, education, work status, occupation and industry, and a series of questions concerning housing characteristics. Development of Specific Areas of the Nutrition Component As in planning for the detailed component of HANES, the final content of the nutrition component was made only after extensive con- sultation with many agencies and individuals. Personnel of CDC provided very valuable advice and assistance, particularly in the development of the nature of the blood analyses to be performed and in planning for the necessary facilities for the extensive laboratory work. To take maximum benefit of the experience of the Ten-State Nutrition Survey, several especially knowledgeable individuals on the staff of the Nutrition Program within CDC who had played an active role in that earlier survey, along with other staff members from the Nutrition Pro- gram, participated with NCHS staff in a work conference directed specifically to the problem of planning HANES. A number of consultations were held with personnel of the U.S. Depart- ment of Agriculture, in both the Agricultural Research Service and the Food and Nutrition Service, who provided valuable input and expert help, as did nutrition specialists within the Maternal and Child Health Service and the Indian Health Service of HSMHA. Assistance was also provided by the Office of Economic Opportunity, the Office of Education, and the Food and Drug Administration, to list but a few of the major contributors. The Food Programs Questionnaire, developed in collaboration with the Department of Agricul- ture, was designed to elicit information about family participation in food stamp and commod- ity programs and the participation of young sample persons in school lunch, breakfast, and milk programs. Data from the questionnaire will be related to the various examination findings as well as to the hematological and blood chem- istry results. Information about participation in food programs such as school lunch programs will be related to dietary adequacy of partici- pants. The medical, dental, and nutrition advisors within DHES played an important role in the development of the medical history question- naires for the nutrition component. Many of the outside consultants and experts in the area were asked to and did review drafts of the forms. Because of the wide age span (1-74) of the population being surveyed, three different ques- tionnaires were developed relative to three different age segments—1-5, 6-11, and 12-74. The first two questionnaires, while essentially alike, differ in content primarily because of the factors of question-recall validity and prev- alence. The questionnaire for age group 12-74 is oriented more toward information associated with the dental and medical conditions that are more prevalent in that age group. One of the three essential parts in obtaining a full nutritional profile of individuals or groups is some assessment of food intake. While food “ consumption data alone are not a valid measure of nutrition, such data help to interpret clinical and biochemical findings. Information about dietary intakes is useful also for such purposes as characterizing food preparation practices, identi- fying sources of nutrients, and determining the types of food consumed at different seasons and in different geographic locations. Although a variety of methods have been developed during the past 40 years to estimate food intakes as part of nutritional status or epidemiological studies, a number of practical considerations influenced the selection of the 24-hour recall and food frequency methods over other methods for HANES. Principal among these considerations were the nature of the data-collecting process and simplicity of the two methods, the fact that data would be analyzed by groups and not by individuals, the limitations of interviewing time, the availability of staff and training facilities, and the recruitment potential for interviewers. In addition, the 24-hour recall method and 7-day food record have been com- pared by several researchers who concluded that for estimating the intakes of population groups, the two methods tend to be interchangeable. Because of the large sample size (30,000), it is anticipated that subgroups, such as age, sex, income, education, family size, health status, and geographic area, will be large enough for analysis to indicate groups of persons where it is obvious that steps need to be taken to improve their diets. Another necessary part in assessing the current nutritional status of an individual is a clinical appraisal that includes general assess- ment by a trained physician looking especially for stigmata of malnutrition and includes taking certain anthropometric measurements. The clini- cal examination was prepared by the Nutrition Advisor to DHES in conformance with accepted criteria for such examinations. The assessment consists essentially of an inspection by the physician of the head and neck for the presence or absence of various signs which are found associated with possible nutritional deficiencies. In addition, it was considered essential that the neck be inspected and palpated for any visible or palpable enlargement of the thyroid gland; that the abdomen be inspected and palpated, and the 11 liver size be determined by percussion in all persons over 25; that the deep tendon reflexes be checked; that the musculoskeletal system be observed for any marked deformities due to possible rickets; and that there be an inspection and palpation of the skin for possible signs suggesting nutritional problems. It was felt that while height and weight were the most simple measurements for assessing nutritional status, the information derived from them would be rather crude. Additional meas- urements were needed for more refined and accurate information on nutritional status in relation to body build and composition. Among the large variety of measurements considered, eight were finally selected in addition to height and weight. These were triceps and subscapular skinfolds to provide a measure of the presence or absence of obesity; triceps skinfold that, when subtracted from the upper arm girth, provides an approximate measure of muscle mass; elbow and bitrochanteric breadth to pro- vide more information on body build, partic- ularly on the bony structure; sitting height to provide a comparison of trunk length in various age-sex groups of different ethnic and socio- economic backgrounds; and head and chest circumferences of children 1 to 7 years of age only, as a source of useful information through their interrelation as possible indicators of early protein-calorie deficiency in that age group. The dental examination planned for the detailed component was expanded in several ways to meet the objectives of the nutrition component. Among these were a more detailed assessment of the gums for manifestations of systemic nutritional deficiencies and diseases, and a series of questions about chewing foods to determine the relationship between dietary in- take and dental conditions. Pilot Testing The first of the pilot test operations was performed in Georgetown, Delaware, from April 27 through May 23, 1970, immediately follow- ing the completion of Cycle III. The main emphasis of this test was on the detailed examination component of the survey, which had been in the planning stages for 2 years. Testing was intended to determine, among other 12 things, the feasibility and acceptability of new examination procedures such as goniometry, pulmonary function tests, tuberculin testing, knee X-rays, thyroid grading, and examination recording forms. Other equally important por- tions of the survey evaluated in this work were questionnaires, interviewing techniques, adminis- trative areas, and the time factors involved in all aspects of the work. A total of 70 persons aged 25-74 were examined during the Delaware work. Much was learned from the first test. Many revisions were required in the coding and sequencing of the questionnaires, and a general appraisal was made of the reliability and rele- vance of items contained in the questionnaires. Problems associated with interviewing were identified, and the amount of time required for household interviewing was obtained. In the examination portion, the procedures that were tried proved feasible and workable with few exceptions. Examples of the exceptions include evaluation of the two types of thyroid grading which had to be deferred until further testing could be performed because of the small number of persons with enlarged thyroid glands. A new piece of equipment to measure respiratory resist- ance presented difficulties in obtaining valid readings. Further trials were also indicated in the area of tuberculin skin testing. Further pretest work followed at the Research Triangle Park, North Carolina, between June 10 and October 6, 1970. With the excep- tion of a small number of persons, all partici- pants were recruited from Government offices in the Research Triangle Park area. A total of 428 persons were examined. As in Delaware, this pretest work was focused on the detailed com- ponent of the survey. With approval from the Office of Management and Budget for the nutrition component which occurred during the last days of the test work at this location, it was possible to examine 25 individuals using the procedures and forms developed for that portion of the survey. These examinations were very important since the examinees were children in the age group 1-6 years, and they provided experience for the first time in the history of the Health Examination Survey with examinees of this age. The detailed examination component was conducted employing certain refinements of procedures initially tried out in Delaware. Several new procedures were tested, however, including laboratory techniques for red and white cell counts, hemoglobin, smears, and a dermatology examination. During the time of this pretest, special training in laboratory proce- dures was provided to the technicians by experts from the Center for Disease Control. The third phase of the pretest work was conducted at the same location, but using a probability sample of persons from Durham County, North Carolina. Several important parts of the overall survey were tested for the first time during this phase. The household question- naire was one of these. This questionnaire, administered by Bureau of the Census inter- viewers, is the first contact with a sample household. It establishes the household composi- tion and obtains certain demographic infor- mation about the households and the individuals who live in them. It is also essential in the selection of persons to be included in the sample. Sample selection procedures, which are complicated by the dual concept of the survey and the use of different sampling ratios for various age-sex groups, were also performed for the first time during this test. The sample selection provided individuals for both the nutrition and detailed examination components. The examination sessions thus in- cluded both types of examinees, permitting the testing of procedures and questionnaires of the two components taken together. The examina- tion also included several procedures not tried previously, such as the ophthalmological exam- ination, collection of urine specimens, and the use of a lung analyzer machine. The equipment for measuring respiratory resistance continued to present difficulties in operation and was later excluded from the examination plan. One of the four medical history supplements to the detailed examination, Supplement D, Gastrointestinal, was also dropped to reduce examination time because it was relatively less important to the survey than were the others. In addition to the examination and question- naire portions of the survey, administrative procedures, consisting principally of record keeping, scheduling and the rescheduling of examinees with broken appointments, school contacts, and transportation of examinees, were also tested. A total of 274 sample persons were identified for this pretest. Of these, 204 were to receive the nutrition portion and the remaining 70 the detailed examinations. At the end of operations, 71 percent of those in the nutrition component and 74 percent in the detailed component had been examined. The fourth phase of pretest work was con- cluded December 17, 1970, in Winston-Salem, North Carolina. Prior to this phase, all forms and questionnaires were reviewed, and many changes were made in wording, sequence, and so forth. Questions not felt to have sufficient validity or relevance to the survey were deleted. The Bureau of the Census questionnaire also under- went some changes, primarily on the question of sources of income where less detail was required of nonpoverty persons. No substantive additions were made to any of the questionnaires or to the examination procedures. The test of visual fields in the ophthalmology examination was excluded because of problems encountered in its adminis- tration. Various sequencing procedures for more efficient examinee flow in the examination center were also tested. During these pretests, new personnel to staff a second caravan were hired for the varying aspects of the survey (interviewers, technicians, nurses, coordinators, and administrative per- sonnel), and the operation of these pretests was a part of their training. The nutrition inter- viewers used during the preceding test had been hired as a temporary arrangement pending the recruitment of permanent personnel. Permanent nutritionists were recruited in time for the last test, and extensive training in this area was given during the Winston-Salem pretest. Following the Durham pretest, a complete package of the HANES material, including a description of the program and sample design, was distributed to the panel of advisors to the National Center for Health Statistics and others, asking for any comments they might care to make concerning the program or any of the specific procedures and forms involved. Replies were received from more than a score of these advisors, and their comments were carefully considered and, in many cases, taken into account in the final version of the HANES plan. The final “dress rehearsal” took place in the Baltimore metropolitan area. The date for the 13 opening phase, household interviewing by the Bureau of the Census, was February 8, 1971, with examinations between March 1 and April 16. Prior to this, however, field employees participated in further formal and informal training sessions in such areas or procedures as interviewing techniques, questionnaire adminis- tration, laboratory, audiometry, dietary inter- viewing, and coding amounts and types of food. They also received an orientation by key staff members of NCHS and DHES. A total of 573 sample persons were included in this final test. Of these, 460 were to receive the nutrition Recipients All households in the sample ® eo eo so. 0 5 8 se 0 0 eo All households containing one or more sample persons © 6 os 8 os eo so 6 eo 0 0 ss ss 8 0 8 eo All sample persons Additional for all sample persons in the detailed component Recipients All sample persons © ® eo eo os os 6 6 0 0 0 6 ss so ss 8 14 portion only, and 113 the detailed examination. The overall examination rate was 66 percent, with 68 percent of those in the nutrition component and 56 percent in the detailed part being examined. Summary The following summary shows the question- naires, procedures, and measurements of the survey, by recipient, as it proceeded through the first 35 of the total 65 primary sampling units: Questionnaires Household Questionnaire Food Programs Questionnaire £7 Medical History, Ages 1-5 General Medical History, Ages 6-11 General Medical History, Ages 12-74 Dietary Intake, 24-Hour Recall Dietary Intake, Food Frequency General Medical History Supplement, Ages 25-74 Supplement A, Arthritis; Supplement B, Respira- tory; Supplement C, Cardiovascular. Supple- ments A, B, and C depend on certain positive responses in other history questionnaires Health Care Needs Questionnaire |General Well-Being Questionnaire Examination procedures and measurements General medical examination Dental examination Dermatological examination Ophthalmic examination Anthropometric measurements Hand-wrist X-rays (ages 1-17 only) Laboratory determinations: Hemoglobin Serum iron Hematocrit Iron binding capacity Red cell count Serum folates White cell count Cholesterol Sedimentation rate Glucose qualitative (urine) MCV Albumin qualitative | MCH (urine) Recipients All sample persons—Con.. . .........c.un. Additional for all sample persons in the detailed component ® 6 eo 6 os os eo oe so 0 0s se 0 8 0 SAMPLE DESIGN General Plan The design of the sample, which is expected yield _approximately- 30, ,000 sample persons for for HANES, is quite similar in a number of ways to th 0 the “designs used in the first three HES cycles. Gener escriptive reports of those de- sighs 25082 re available, as is a more detailed report of the Cycle II sample desighi.55) NCHS set specifications for the sample design and carried out some of the steps of drawing the sample. Other steps in the design and sample selection were performed by the Bureau of the Census under a contractual arrangement. The primary similarity of the design to that of the HES cycles is that it is a multistage, stratified, probability sample of loose clusters of persons in land-based segments. The successive elements dealt with in the process of sampling are primary sampling unit (PSU), census enumer- ation district (ED), segment (a cluster of house- \ Thyroid (T-3, T-4) Examination procedures and measurements MCHC Occult blood qualitative Vitamin A (urine) Vitamin C Creatinine (urine) Magnesium Thiamine (urine) Total protein Riboflavin (urine) Albumin Iodine (urine) Extended medical examination X-rays of chest and major joints (hand-wrist, knee, hip) Audiometry (air and bone) Electrocardiography Goniometry Spirometry Pulmonary diffusion Tuberculin test Laboratory determinations: Bilirubin Phosphorus SGOT W.B.C. differential count Alkaline phosphatase Serological tests for Uric acid amebiasis, measles, Calcium tetanus, diphtheria, rubella, polio holds), household, eligible person, and, finally, sample person. The HANES design was further complicated, however, by the fact that unlike the preceding cycles it had two distinct examination compo- nents—nutrition and detailed—to be considered instead of only one. Similarly, the age range in HANES covers more than one specific age group, and emphasis is placed on the low-income groups, preschool children, women of child- bearing age, and the elderly, because these are the groups liable to be affected most often by malnutrition and for which detailed information is most needed. Therefore, the design had to take into consideration the sample size require- ments for the population subgroups to obtain an optimum mix for reliability of estimates. Design Specifications The sample design of HANES was developed essentially from a set of specifications that took 15 into consideration the requirements and limita- tions placed upon it. It was important that the requirements be consistent with survey objec- tives and that the limitations not be so serious as to materially distort the objectives. Specifi- cations considered to be of primary importance were as follows: 1. The target population would be the civilian, noninstitutionalized population 1-74 years of age residing in the coter- minous United States, with one excep- tion. Because of operational difficulties experienced in Cycle I, all people residing upon any of the reservation lands set aside for the use of American Indians would be excluded. 2. For the nutrition component, broad national estimates must be made annual- ly, with more detailed estimates pub- lished upon the completion of a 2-year cycle. For the detailed examination, broad national estimates would be based on data collected during the 2-year cycle, with more detailed estimates being made after the completion of the two succes- sive 2-year cycles. 3. Three mobile examination centers similar to the ones used in earlier cycles of HES would be used. Thus, with appropriate modifications, the survey would be based on administrative and logistical proce- dures that have been developed and proved over a period of more than 10 years. A team could examine about 20 persons per day; of these, all would receive the nutrition examination, and four would receive the detailed examina- tion. Other time limitations were a 5-day workweek, a loss of 5 weeks per year due to vacations and holidays, and a loss of 7 days per move from one examining loca- tion to another. 4. Operationally, the three caravans could visit a maximum of about 65 PSU’s over a period of approximately 2 years. 5. A team must stay at least 3 weeks at a stand because of the expense of moving and the need to allow enough time in an area to give sample persons adequate time to be examined. A team cannot stay in an 16 area longer than 6 weeks because of the requirement to finish the survey in 2 years. 6. Because of the considerations in items 3-5 above, there would be a minimum number of 300 and a maximum number of 600 sample persons for each stand. 7. To the extent possible, the schedule of examining locations must take account of climate. 8. About 20 percent of the sample should be selected from the population classified at or below the poverty level. Other groups of special interest are preschool children, women of childbearing age, and the aged. 9. The estimates from the survey would be of two kinds: (1) distributions of the population by specified characteristics such as height, weight, blood pressure, and selected biochemical determinations; and (2) prevalence in the population of selected chronic conditions, particularly those in the arthritic, respiratory, and cardiovascular groups. 10. Maximum target tolerances for sampling variability would be set for several key statistics, permitting a general analysis by | broad geographic regions, population size groups, and other major subgroups such as income, race, age, and sex. 11. Data from the 1960 Decennial Census would have to be used in the sampling procedures until 1970 data become available. Stratification and Selection of Primary Sampling Units The first-stage sample consists of 65 geo- graphic areas, or PSU’s. These have been selected from among approximately 1,900 PSU’s into which the geographical territory of the mainland has been divided. Each PSU consists of a county or a small group of contiguous counties. For the purposes of the design of the Health Interview Survey, one of the other major NC data collection programs, PSU’s are stratified _into 357 groups, and one PSU is selected from each. stratum _with_a_probability proportional to_its_ Fifteen of the a “contain only one very large metropolitan area of more than 2,000,000 population, and thus were chosen into the sample with certainty. The others were grouped into 25 superstrata on the basis of geographic region and population density class, as shown in table 1. Then, using a controlled selection technique to assure representation of specified State groups and of classes by rate of population change, two PSU’s were chosen from each of the 25 strata with probability propor- tional to the PSU’s 1960 population. Thus the sample contains 65 PSU’s. A listing of the PSU’s is given in appendix I, along with definitions of geographic region, State groups, and classes by rate of population change. To provide the ability to make early national estimates, PSU’s were divided randomly into two parts. Thus, the survey cycle of 2 years will be conducted in two rounds. The first round involves 35 locations, including 10 of the large metropolitan areas and 25 of the smaller, non- certainty PSU’s. Table 1. Number of self-representing and nonself-representing superstrata for the Health and Nutrition Examination Survey design, by region and population density class, with average size of superstrata and definitions of population density classes Number of superstrata Average size of Region ang Population superstrata, Definitions of population density classes density class Total Self- Nonself- 1960 population ola representing | representing in millions All regions ......... 40 15 25 4.5 Northeast . conv ionsrivs 13 9 4 3.4 Largest SMSA's ............ 9 9 - 2.7 | SMSA population greater than 2.4 million. Other large SMSA's . ......... 1 - 1 5.2 | 70% or more of SMSA'’s population was urban. OtherSMSA's ............. 1 - 1 6.5 | Less than 70% of SMSA's population was urban. Non-SMSA, urban . .......... 1 - 1 4.1 | 40% or more of the population was urban. Non-SMSA, rural ........... 1 - 1 4.8 | Less than 40% of the population was urban. MIGWESBE sw ve ssmsw sins 10 3 7 4.8 Largest SMSA's ............ 3 3 - 3.5 | SMSA's population greater than 3 million. Other large SMSA's .......... 2 - 2 4.3 | 90% or more of SMSA's population was urban. Other SMSA's ............. 2 - 2 5.3 | Less than 90% of SMSA's population was urban. Non-SMSA, urban . .......... 2 - 2 5.9 | 34% or more of the population was urban. Non-SMSA, rural ........... 1 - 1 6.2 | Less than 34% of the population was urban. SOW ,ivvnsvcasanses 8 - 8 5.4 Largest SMSA's ............ 2 - 2 4.8 5 ; ‘ Other large SMSA’s . . . .. ..... 1 i 1 5.1 90% or more of SMSA's population was urban. Other SMSA'S oui snninmvins 1 - 1 4.5 | Less than 90% of SMSA's population was urban. Non-SMSA, urban . .......... 2 - 2 6.0 | 30% or more of the population was urban. Non-SMSA, rural ........... 2 - 2 5.9 | Less than 30% of the population was urban. WEST 20 sie vd ld Ba Bla alle 9 3 6 4.8 Largest SMBA'S .. cv. vvmsi un 3 3 - 3.2 | SMSA population greater than 2.5 million. Other large SMSA's . ......... 2 - 4 6.0 | 72% or more of SMSA's population was urban. OtherSMSA's ............. 1 - 1 6.2 | Less than 72% of SMSA's population was urban. Non-SMSA, urban . .......... 2 - 2 5.0 | 36% or more of the population was urban. Non-SMSA, rural ........... 1 - 1 5.0 | Less than 36% of the population was urban. 17 ~~ Within PSU Design For the first 44 HANES stands, only 1960 census data were available for the purpose of sampling within PSU’s. The remaining 21 stands will use 1970 census data, resulting in a different procedure for within-PSU sampling. A principal reason for this change is that socioeconomic changes within ED’s from the time of the 1960 census until the start of HANES precluded a satisfactory method to classify ED’s efficiently into poverty and nonpoverty groups. This classi- fication can now be made using the 1970 data. For the stands using the 1960 data, ED’s in each PSU were divided into segments of an expected six housing units each. In urban areas where listing units were well defined in 1960, this division was quite accurate since the sam- pling frame was composed of listings that resulted from the 1960 census. For ED’s not covered by the listing books, area sampling was employed and, consequently, some variation in the seg- ment size occurred. To make the sample repre- sentative of the current population of the United States, the list segments were supple- mented by a sample of housing units that had been constructed since 1960. Then a systematic sample of segments in each PSU was selected. The ED’s that fell into the sample were identified and coded into two economic classes. One of the classes, identified as the “poverty stratum,” was composed of “current poverty areas’ that had been identified by the Bureau of the Census in 1970 (pre-1970 census) plus other ED’s in the PSU with 1959 mean income less than $3,000 (based on the 1960 census). The other economic class, identified as the “nonpoverty stratum,” included all other ED’s not designated as belonging to the poverty stratum. A description of how the current poverty areas were determined is given in appendix I. For those sample segments in poverty stratum ED’s, all scgments were retained in sample. For those sample segments in nonpoverty stratum ED’s the segments were divided into eight random subsamples, and one of the subsamples was chosen to remain in sample for HANES. One advantage from sampling the nonpoverty stratum in this way related to the need to have reserve segments in case the sample of persons in a PSU is less than the specified minimum of 300. 18 For the remaining 21 stands, 1970 census data will be used. ED’s in each PSU will be divided into segments of an expected eight housing units each. As in 1960, the 1970 urban segments will be more stable in size than area segments. For each PSU using 1970 materials, ED’s will first be sorted into poverty and nonpoverty strata. The proportion of persons in poverty will be used to determine the poverty and nonpoverty status of each ED. The desig- nated proportion will vary from stand to stand. The poverty indices will be based on 1969 income (1970 census), size of family, sex of head of family, age (65 years or under) of head of family, and farm-nonfarm status. The sam- pling rate for selection of segments from the 21 stands will be changed from a poverty- nonpoverty ratio of 8:1 to a ratio of 2:1. This change is being made as a result of a study using 1970 data by the Bureau of the Census that indicated a significant decrease in the sampling variance could be obtained by employing the 2:1 ratio. Then a systematic sample of segments will be drawn from each poverty-nonpoverty stratum at different rates. As in using 1960 materials, reserve segments from 1970 materials will also be provided to meet the specified minimum of 300 sample persons per stand. Selection of Sample Persons After the sample segments have been identi- fied, a list of all current addresses within the segment boundaries is made, and the households are interviewed to determine the age and sex of each household member, as well as other demo- graphic and socioeconomic information required for the survey. If no one can be found at home after repeated calls or if the household members refuse to be interviewed, the interviewer tries to determine the household composition from neighbors. To identify the sample of people to receive the nutrition examination, the household members aged 1-74 in each segment are listed on the Sample Selection Worksheet as illustrated in figure 2, with each household in a segment numbered serially from 1 through KX, the number of households in the segment. The household members are listed on the worksheet Form HES-7 (Cycle IV) U.S. DEPARTMENT OF COMMERCE | 1. HES 2, HES STAND NAME 3. SEGMENT NO. (2-22-71) BUREAU OF THE CENSUS STAND NO. SAMPLE SELECTION WORKSHEET 4. INTERVIEWER’S NAME 5. CONTROL NO. Interviewer — Enter Person Number (Cols. d—i) HH ON DAY AGES SER. COM- 25-44 20-24 NO. | INTERVIEWS | "con 65-74 45-64 f) (2) 6-19 1-5 (a) (b) (c) (d) (e) MALE | FEMALE MALE | FEMALE (h) (i) A — With | | J EFS i 2 3 Ne [Person | rs 1 |A = Without | No, of | | EP's non EP’s | | 8 | C | ) A = With ] 9 3 4 EP’s | | JZ lo ___] | | 5 Person ! ! 2 | A = Without | No. of | | EP : ! ! 5 non EP's | | : | | c | | A — With 9 | ' EP's | | vd oo wn] ! * Person ! | 3 A — Without | No. of | | EP's non EP's | | B | | | | C | | I 1 A — With J | EP's : No, [Ten | P n 4 A — Without rr | —— i EP's non EP’s| — — | n—— ih — —— | g 0 - out | No. _. | - | EP’s non EP's B | | C | | 1 i PL _ TAKE ALL 1/4 1/4! 1/2 1/4 | 1/2 1/4 1/2 WASHINGTON USE ONLY — TOTALS Hy NED AoA» INTERVIEWED PERSONS INCL. EXTRAS |EP’S 65-74 45-64 M25-44 | F 25-44 M 20-24 IF 20-24 6-19 1-5 : } EXTRA HHS NONINTERVIEWED HOUSEHOLDS HOUSEHOLDS [INTERVIEWED LE TYPE A TYPE B TYPE C VIEWS TOTAL WITH EP’S TNUMBER EP'S [WITHOUT EP’S 1 1 Figure 2. Sample Selection Worksheet. USCOMM-DC in the order of that serial number. The entry made on the worksheet corresponds to the person’s column number on the household questionnaire. For example, column 1 is re- served for the household head. The spouse, if any, is usually listed in column 2, while the children and other household members are listed in succeeding columns of the questionnaire. Suppose the first three households in a segment have the following age-sex composition: 19 Household serial number Column number on questionnaire 1 2 3 4 5 6 LT 5 5h ao ums scx mrs sm sn ton ms 1p Male, Female, | Female, | Female, age 45 | age 42 age 13 age 16 years | years years years 2 mE rr ra waa 8 Male, | Female, | Male, Female, | Male, | Female, age 34 | age 27 age 7 age 5 age 3 age 6 years | years years years years | months a vie ow we UE BE RE Male, Female, age 75 | age 70 years | years These household members would be recorded on the worksheet as shown in figure 2. Note that two persons are not listed; one is 75 and the other is only 6 months of age and, therefore, they are not part of the target population of persons 1-74 years of age. After the Sample Selection Worksheets are put in order by seg- ment number, a systematic random sample of each age-sex group is selected, using the sam- pling rates shown at the bottom of the work- sheets. There still remains one sampling operation— selection of adults to receive the detailed health examination. Overall, about 20 percent of the total sample receive the detailed health examina- tion, producing a subsample of about 6,000 persons. This group is a subset of the nutrition sample aged 25-74, inclusive; the sampling frame is the nutrition sample designated on the Sample Selection Worksheet. The subsample is chosen systematically after a random start, using the sampling rates shown in table 2. , The sample size varies from one PSU to another, depending on the PSU population and the number of persons living in the low-income ED’s. For the reason stated in the design specifications, the design provides for a probabil- ity sample of reserve segments to insure the number of expected sample persons per PSU. A deletion procedure is employed as necessary to reduce the number of sample persons per PSU to the number expected. Table 2. Subsampling rates and expected sample size by age and sex for the detailed health examination Both sexes Males Females Age Expected Fars Expected Rats Expected sample size sample size sample size TOMA (vv 26 mommies BE BED BE & SAREE EE FE 6,000 2,850 3,150 25-QAYOUIS «sco» vovaion vn rir ann a 2,000 2/5 1,000 1/5 1,000 45-64 years ........ i 2,700 3/5 1,300 3/5 1,400 BETA YBAIS vous svnminnsss mmusss senses sss 1,300 1/4 550 1/4 750 20 OTHER SAMPLING ASPECTS Sampling Features of the Examination The sampling aspects of the survey are not restricted to choosing the sample persons and having them participate in the examination. The conduct of the examination itself has numerous sampling features that should be mentioned. Examinations will be conducted in 65 differ- ent locations throughout the United States by three different teams of examination staff. Each team for any one location consists of a physi- cian, dermatologist, ophthalmologist, dentist, two health technicians, laboratory technician, and two dietary interviewers. Because of normal personnel turnover and the lack of availability of dermatologists and ophthalmologists for ex- tended periods of time over 1 month or even shorter duration, the number of different exam- ining staff members employed through the 65 locations will be quite large. At the time of preparation of this report, it was estimated that the total number of individuals in each of the above positions for all locations would be approximately 30 physicians, 65 dermatologists, 100 ophthalmologists (for 35 stands only, see p- 30), 9 dentists, 15 health technicians, 10 laboratory technicians, and 20 dietary inter- viewers. Ideally, assignment of each examinee to the particular parts of the examination should be random with respect to time, place, and examiner. Operationally, such assignment is impossible. Therefore, any peculiarities in the conduct of a part or parts of the examination _ procedures, difficulties with equipment, or ‘changes in the standards of the laboratories doing blood chemistry analysis may be reflected in the examination findings as a “place peculiarity. Stand Sequencing and Scheduling As in previous cycles of HES, the scheduling of stands for HANES has been deliberately arranged so that the North is avoided in winter and the South in summer. Such scheduling is a airly obvious operational necessity as it would be quite impractical to conduct a mobile exami- nation survey of this kind in the Northern States &£ in the middle of the winter. The schedule of stands for HANES is shown in table 3. While this type of scheduling is desirable from an operational point of view, it can produce certain limitations on the examination data. Any characteristic under study which may have a seasonal variation will be difficult to interpret by geographic region. For example, to the extent that if persons in all parts of the country weigh more in winter than in summer, the mean weight of northerners would be underestimated and that of southerners overestimated. Another area of concern is the effect of season on the quality of data. For example, relatively more poor diets were reported in the spring than in other seasons in the recent U.S. Department of Agriculture Food Consumption Survey. Possi- bilities such as these must be taken into account in analysis of the data. The limitations resulting from such a scheduling arrangement, however, were not considered to be too serious in either Cycle II or Cycle III. Most of the characteristics of the examination in the age group 6-17 did not exhibit any marked seasonal variation. Even in Cycle I, where the focus of the examination was on chronic conditions in the adult population, seasonal variation was not considered to be a serious problem. This would not be true if the examination, in any of the cycles, attempted to obtain estimates of conditions such as acute respiratory disorders. An important consideration in sequencing stands is economy of operation. Efforts are made to follow the seasonal pattern described with a minimal amount of travel necessary in moving from one stand to the next by sequenc- ing with regard to geographic proximity. Individ- ual stand time schedules, featuring the various operational aspects involved in conducting the examinations at a particular stand, are also required in the development of the sequencing. Time allowances are based on the distance between stands and, therefore, the time required for movement of the trailers and personnel between stands, the time required for census interviewing, followup by the health examina- tion representative (HER), trailer setup, staff setup and dry runs, staff vacation periods, and examinations. The number of days allotted for examinations is dependent upon the expected sample size at a particular stand and is deter- 21 Table 3. Schedule of stand operations by caravan, Health and Nutrition Examination Survey: 1971-73 Caravan | Caravan 11 Caravan 111 Dates of field operations Location Stand 1 Location Sund 1 Location Stend y number number number 1971: AorMEY sus sos s oe Philadelphia, Pa. 1 | Pittsburgh, Pa. J 2 May-June .........o... Albany, N.Y. 3 | Mercer, Pa. 4,2 | 2... 2 2 2 Jumduly EW RE EE RE Bovion, Mas, | 5 Detroit, Mich. {5 (4) a ow y-August ........... (5) (6) Newark. NJ { 7 August-September . ...... Springfield, Mass. 8 Bay City, Mich. 10 Li (7) September-October ...... New York, N.Y. 11 La Porte, Ind. 12 Angola, Ind. 13,0) eel ) } } ) ) Cabarrus, N.C. ", Hp Los Angeles, Calif. foe, Savannah, Ga. { id 1972: January-February ....... West Palm Beach, Fla. 17 Tucson, Ariz. 18 San Antonio, Tex. 19 February-March ........ Barbour, Ala. 20 Fresno, Calif. 21 Avoyslies, La { 22,19) March-April ........... Columbia, S.C. 23, (20) | San Francisco, Calif. 24 rr (22) April-May ............ 26, (23) | Clallum, Wash. 27,(24) | Lamar, Miss. 25 May-June . ............ | New York, NY. {2 Grant, Wash. 30, (27) | St. Joseph, Mo. 28, (25) JUASSUIY oe «wo 5 win be Hartford, Conn. 29, (26) | Boone, lowa 33 Chicago, Il {3 (28) July-August ........... Sussex, Del. 32, (29) | Washington, D.C. 34 yh (31) August-September . ...... Milwaukee, Wis. 35, (32) | Oak Hill, W. Va. 39, (34) | Cleveland, Ohio 9, (31) September-October ...... Omaha, Nebr. 38, (35) {*" (39) | Knoxville, Tenn. 42, (9) October-November ...... - 37, (38) | Dallas, Tex. (41) 40, (42) November-December . . . . . }| Chillicothe, Ohio (37) (41) | Natchitoches, La. { (40) December-January . ...... (40) 1973:3 January-February ....... Tampa, Fla. 45 Globe, Ariz. 44 New Orleans, La. 43 hi ] i ; ; } : : } i} Morristown, Tenn. feo, #3 San Diego, Calif. i Statesboro, Ga. April-May ........«c.x> St. Louis, Mo. 49 Minneapolis, Minn. 62, (47) | Philadelphia Il, Pa. B81 May-June ............. Fillmore, Minn., Howard, lowa 52 Ottertail, Minn. 59 Chemung-Tioga, N.Y. 36 JUNE «ov vv vr sie sus : {95. (52) | Fargo, N. Dak. 56 Scranton, Pa. 57 July-August ........... } Chicago 11, 11. (65) {6s (56) | Providence, R.I. 54 August-September . . . . . . . Columbus, Ohio se | Sr-losnb, Mick. (65) | New York V, N.Y. 63, (54) September-October . ..... Bedford, Pa. 61 Monterey, Calif. 53, (65) New York IV. N.Y 460, (63) October-November ...... R Ke. V {o4. (61) Los Anasles II. Calif 50 (60) November-December . . . . . } DAROKE VE: (64) oranges, bat, { (50) !Stand locations are counties, cities, or towns in which the examination center is located. Sample areas from which examinees are drawn for the stand consist of the PSU's, which may include several counties. Numbers in parentheses indicate a carryover for the stand number into the last month of the month group. 2Not in operation. 3Schedule for 1973 is tentative. mined on the basis of approximately 19 sample persons per day. Schedules for two stands for each caravan are shown in table 4. ADVANCE ARRANGEMENTS Professional Relations Before the interviewing or examination proce- dures can be started in a sample area, advance arrangements involving professional relations, public relations, and arrangements for the logis- tical requirements of the survey are necessary. 22 The conduct of the survey in any specific area is the responsibility of the Public Health Service (PHS), as distinct from the State or local health authorities or others in the area. In addition to notifying various directors within the regional offices of the Department of Health, Education, and Welfare, it is the policy of the survey to fully acquaint the State and local health author- ities and the medical, dental, and osteopathic professional organizations in the States and in the communities with the HANES objectives and method of operation. Since school children are involved in the survey, the State and local Table 4. Excerpt from HANES schedule of stands Caravan schedule Operation Caravan | Caravan || Caravan 111 Standnumber ..........v5000509 20 21 22 LL OCBYUON 4 iv ecv v0 5 women oicacie: at wai so ails 6 Barbour, Ala. Fresno, Calif. Avoyelles, La. SANPIS SIZE vv oiwn iv vinnie waa ow 600 350 590 OFFICE SBIUD «wus vs 5 wv 500 ® 5 vm anes Feb. 4, Fri. Jan. 28, Fri. Feb. 25, Fri. Census interviewing . .............. Feb. 7, Mon. Jan. 31, Mon. Feb. 28, Mon. HERTOHOWUP ..o:vivismnamme sei Feb. 15, Tues. Feb. 8, Tues. Mar. 7, Tues. Examination center arrival .......... Feb. 29, Tues. Feb. 15, Tues. Mar. 14, Tues. Examination centersetup . .......... Mar. 1, Wed. Feb. 16, Wed. Mar. 15, Wed. Staff setup and training ............ Mar. 2, Thurs. Feb. 17, Thurs. Mar. 16, Thurs. DIVING ocovevommvmmesmnnsiswmms Mar. 3, Fri. Feb. 18, Fri. Mar. 17, Fri. Examinations ; . ;ccssnssmansmmasio Mar. 4, Sat.-Apr. 18, Tues. Feb. 19, Sat.-Mar. 17, Fri. Mar. 18, Sat.-Apr. 29, Sat. Dismantle-transit ................ Apr. 19, Wed. Mar. 20, Mon. May 1, Mon. SIENA NUMBEr uu esneshvmmsan na 23 24 25 LOCBHON wisn vsmws smmpnimms sim we Columbia, S.C. San Francisco, Calif. Lamar, Miss. SUNPIE ZG . viv usrmnsmmtsmesn 300 570 440 OHICESBIUP «ov vio wis sm mia caw osm ais 8 Mar. 31, Fri. Feb. 25, Fri. Apr. 7, Fri. Census interviewing . . ............. Apr. 3, Mon. Feb. 28, Mon. Apr. 10, Mon. HER OIOWUD viva nis eames messes s Apr. 11, Tues. Mar. 7, Tues. Apr. 25, Tues. Examination center arrival .......... Apr. 20, Thurs. Mar. 20, Mon. May 2, Tues. Examination centersetup . .......... Apr. 21, Fri. Mar. 21, Tues. May 3, Wed. Staff setup and training ............ Apr. 22, Sat. Mar. 22, Wed. May 4, Thurs. DIY IUNS ;csvnssnnssnnvaswnersss Apr. 24, Mon. Mar. 23, Thurs. May 5, Fri. EXUNINAHONS «0: 405500 30 050w 00 0 00 Apr. 25, Tues.-May 16, Tues. | Mar. 24, Fri.-May 4, Thurs. | May 6, Sat.-June 8, Thurs. Dismante-transit ....cs:5 05 50a ons May 17, Wed. May 5, Fri. June 9, Fri. officials concerned with public schools are also informed, as are the appropriate local and diocesan officials of the parochial schools. A letter announcing the survey, the local areas to be sampled, and the dates of survey opera- tions and a brochure describing the survey are mailed 3 to 4 months before examinations are scheduled to begin, to the Health, Education, and Welfare regional offices, State medical and osteopathic societies, local medical societies, and State and local health departments. A request is made of the State and local medical and osteopathic societies that an enclosed profes- sional release be printed in their respective professional journals. The letter to local health authorities includes a request to provide HANES with a listing of local and State health agencies, clinics, and medical services to whom HANES examinees without present medical resources and requiring medical care may be referred, or to whom a report of -their examination findings may be sent. About 2 months before examinations begin, the HANES Dental Advisor consults the PHS regional dental program director for the area. Following the regional director’s recommenda- tions, telephone calls are made and then letters are sent to the State dental director, who informs the State and local dental groups about the survey plans. Occasionally, letters are sent by the HANES Dental Advisor to State and local health dental groups on the advice of the regional director. Three to 4 weeks after the mailing of the initial letters, the local health authorities are called by telephone, and any further questions about the survey are answered. Personal visits by HANES medical and dental advisory staff are made to any health agency or society making such a request. Public Relations A general news release explaining the program is prepared for each sample area and is distrib- uted to local news media. The release is timed to coincide with the start of interviewing by the Bureau of the Census. As a result, local news- 23 papers at most of the locations publish items concerning the program. No special effort is made to have radio and television stations publicize the survey, but at some locations members of the staff have been interviewed by these media and film has been taken to be televised. Under no circumstances, however, are pictures or films taken of any sample examinee since this would be a breach of the promise of confidentiality. Sample households having a mailable address (house or post office box number) are sent an “advance” post card by the Bureau of the Census several days before their personnel begin interviewing. This card informs the household members that a Bureau of the Census inter- viewer will be calling at their home within the next few days in connection with a survey being conducted in the area for the Public Health Service. Logistical Arrangements Four to 6 weeks before the start of a stand, a member of the HANES field ‘staff, the Field Operations Manager (FOM), visits the sample area to make physicial arrangements for the mobile examination center and the administra- tive office, to meet personally with local health and school officials, and to initiate the many logistical actions required for the survey. Selec- tion of a site for the Health Examination Center is extremely important to the success of the survey. The following items are considered: 1. Location of sample households and trans- portation arteries 2. Community attitude toward the location 3. Proximity to power, water, and sewer connections 4. Reasonable freedom from noise and/or excessive vibration . Availability of living accommodations for the staff within a reasonable distance 6. Adequate space to accommodate trailers and cars of staff 7. Availability of office space near the exam- ination site for the administrative office ot During this visit to the sample area, the FOM also arranges for electricity, water, sewerage, 24 telephone, and transportation services. Any other logistical arrangements required before the arrival of the mobile examination center and the staff are also taken care of at this time. Within the time allowed, the FOM makes a courtesy visit to the local health department and contacts the superintendents of the larger school districts to explain the program. HOUSEHOLD INTERVIEWING PROCEDURES Census Interviewing Trained Bureau of the Census personnel call on all housing units contained in the segments of the sample area to determine their household composition and to obtain demographic and other data if the household contains any eligible persons aged 1-74 years, inclusive. They pave the way for the HES interviewers who subsequently visit the household. Each of the households should have received the advance post card from the Bureau of the Census informing them of the visit. The front of the household questionnaire, shown as appendix IIA in part B of this report, contains standard Census identification entries related to the housing unit and space for recording information on calls. On the inside of the questionnaire, questions 1-3 identify all persons living in the household, according to relationship to the head of the household, age, race, and sex. If the household does not contain any persons in the age range 1-74, inclusive, the interview is concluded. If the household does contain persons eligible for inclusion in the survey, the remaining ques- tions may be asked of any responsible adult member of the household. A callback is made by the Census interviewer if a responsible adult is not present initially. At the end of the interview, the interviewer leaves a thank-you letter signed by the Surgeon General. The interviewer ex- plains that if anyone in the household is selected, a representative of the Public Health Service will be calling again within a week or so to explain the survey. The interviewer also inquires as to the best time of the day for the representative to visit the household. The role of the Census interviewers ends after all household questionnaires have been edited by the Census supervisor for omissions or incon- sistencies and turned over to the HANES field management office. HANES Interviewing The FOM and the Field Management Assist- ant (FMA) draw the nutrition sample daily as the household questionnaires are turned over to them. The sample for the detailed examination is drawn at the end of the week. A master list is prepared giving the name, age, race, sex, and household identification of each person selected. In the event that the number of persons on the master list significantly exceeds a predesignated expected number for a particular stand, a subsampling pattern is provided to reduce the sample size to the maximum number that can be handled according to the schedule. All persons remaining on the master list then receive a sample number. Those receiving only the nutri- tion examination are given numbers in the 001-599 series; the detailed examinees are given numbers in the 600-799 series. After Census interviewing is completed and the master list prepared, HANES representatives (HER’s) visit all households containing sample persons. The main purpose of this visit is to get the sample person(s) to make an appointment to come in for the examination. During the inter- view, the HER administers one of the medical history questionnaires (appendixes IIC-IIE, part B) as appropriate for the age of the sample person, a Food Programs Questionnaire (appendix IIB, part B), and the General Medical History Supple- ment, Ages 25-74 (appendix IIF, part B), if the sample person is to receive the detailed examina- tion. The HER obtains written consent for the examination of any minors and gets a written authorization to obtain additional information from the records of physicians, dentists, hos- pitals, schools, and State registrars. The HER indicates to the sample person that the Public Health Service will be glad to send a report of significant findings to his physician (or clinic) and dentist if he so wishes. In the course of the interview, the HER must be able to explain the program fully and to answer many questions, such as how the sample was selected, examination content, and value of the examination to the individual. They must also be alert to signs of noncooperation and try to overcome it. APPOINTMENT AND TRANSPORTATION PROCEDURES The HER carries a copy of the master appointment schedule, the original of which is kept in the field management office. This schedule calls for four morning sessions (in- cluding Saturday), four afternoon sessions (in- cluding Saturday), and two evening sessions. Ten persons (two detailed examinees and eight nutri- tion examinees) can be seen in any one session. The HER’s schedule two detailed and five nutrition examinees for the beginning of the session and three additional nutrition examinees 1% hours later. Once the sample person has agreed to come in for the examination, a convenient time is worked out, and the informa- tion is telephoned to the office from the household. The sample number for that person is then entered on the master appointment schedule. Finally, an appointment slip is left with the sample person indicating the day and date on which he is to be examined and the time that the taxi will call. The use of a taxi, for which arrangements have already been made, is encour- aged because it reduces the chance that the sample person will not appear. Some sample persons elect to drive themselves to the examination center and be reimbursed at the rate of 10 cents a mile. If the HER’s think an appointment is “shaky,” they may offer to pick up the sample person themselves. At least 3 days before the date of examination, a reminder notice (a duplicate of the one left in the home) is mailed to the person. On the day before the examination, a list of names and addresses of examinees is furnished the taxi company. For those sample persons of school age, a written excuse is obtained from the parent or guardian during the interview; this excuse is given to the taxi company, HER, or sample person, depend- ing on where and when he is being picked up. There are always a number of persons who, for one reason or another, cancel their appoint- ments or are not available at the time they are to be brought to the center. Those who cancel are 25 fairly easily rescheduled for another time. Those who fail to appear without any notice of their intention to do so or who change their minds about participating are followed up as soon as possible, preferably the same day by the same HER. Immediate followup of these persons helps to reinforce in the sample person’s mind the importance placed on his participation. In many cases, the person can thus be brought to the examination center only a little later than originally scheduled. EXAMINATION CENTER AND FIELD STAFF As in the preceding three cycles, examinations are carried out in a specially constructed mobile examination center (MEC). For the HANES program, nine new trailers, 45 feet long and 8 feet wide, were constructed. The individual trailers are drawn by detachable truck tractors when making moves from one area to another. Three trailers are set up side by side and connected by enclosed passageways to make each examination center. Figure 3 shows the three trailers included in each MEC and the floor plan of each. A minimum space of 50 feet by 50 feet is required to accommodate the MEC. The site on which the MEC is located must be hard surfaced and as level as possible to avoid any effect on certain examination procedures and to be accessible to the truck tractors. Heating and air-conditioning units are installed to help pro- vide a standardized environment for conducting the examinations. The field staff necessary to carry out the three-team operation of the survey may be considered to consist of three elements. The first element is the team of Census interviewers (usually 8 to 16 persons) and a supervisor. The second element consists of the administrative staff and HES interviewers. The administrative staff (the field operations manager and one assistant) arrive at the location and set up their office on the Friday before Census interviewing, with from four to six HER’s arriving 1 week later. The total administrative staff consists of five field operations managers, five field manage- ment assistants, and 12 HER’s. The adminis- trative staff includes extra positions because their operations at a new sample area begin 26 before examinations at a preceding area are completed. With three teams performing exam- inations, four and sometimes five locations are operating simultaneously. The third element is the examining staff operating within the mobile examination center, which includes a physician, a nurse, a dermatologist, an ophthalmologist, a dentist, two dietary interviewers, two health technicians, one laboratory technician, and a coordinator. With the exception of the dermatologist and ophthalmologist, all other members of the field staff are civil service employees or commissioned officers of the Public Health Service. The derma- tologist and ophthalmologist are usually senior residents who generally are employed only for a single sample area. EXAMINATION CENTER PROCEDURES General As discussed earlier, the content of the examination was developed after extensive plan- ning, consultation, and methodologic and pilot studies. Thus, it is a special examination tailored to meet the objectives and limitations of the survey and its two components and is not intended to be a complete medical examination. The fact that the examination is not a substitute for a visit to the examinee’s own physician and dentist is explained to the sample person or to the parents or guardians of sample children. A report of medical findings for each examinee receiving the detailed examination is sent to the examinee’s physician or clinic. This report in- cludes any new significant medical, derma- tological, and ophthalmological findings; data on height, weight, visual acuity, hearing levels; and the results of urinalysis, hematology, blood chemistries, and the tuberculin skin test. En- closed with the report are a copy of the chest X-ray and a tracing and computer printout of the electrocardiogram. Reports of medical findings of nutrition examinees are sent only if there are any new significant medical, dermatological, ophthal- mological, urinalysis, hematological, or blood chemistry findings. A complete report is sent for all of these areas if the results in one or any part TRAILERS CTT TTT Body Wash |! i | oasuremants Cardio-pulmonary OOH | Audiometry | | | Staff I | room | oo ene Staff ra entrance Physical Dermatology Wash examination examination room Dark X-ray ee room Dietary interview Waiting Laboratory Dental Ophthalmology area ] examination examination Dietary interview Examinee entrance FLOOR PLAN Figure 3. Mobile examination center. 27 of one, such as a biochemical test, are found to be abnormal. Since the reports of detailed and nutrition examinees are necessarily delayed because of the processing of blood chemistries, any condition found that, in the opinion of the examining physician, requires early medical attention is reported immediately by phone to the personal physician or medical care facility identified earlier by the examinee. A number of examinees are unable to provide the name of a regular physician or medical resource to whom they wish to have their findings reported. In such cases, the approval of the examinee is obtained during the household interview to have the findings referred to a source, such as a county health department, that had been obtained as a result of the advance professional relations described in an earlier section. These sources are aware of the HANES program and have been alerted to the possibility of receiving reports of findings. Reports of dental findings are mailed by the dentist in the field for all examinees requesting a report. Conditions that require immediate attention are handled individually, usually by phone. For an examinee who does not have a regular dentist and for whom immediate atten- tion is required, after obtaining the patient’s approval the referral service of the local dental society, the personal physician of the examinee, or other medical-dental source is informed. All forms used in the conduct of the examina- tion procedures as well as the questionnaires administered within the examination center are shown as appendixes IIG-IIQ in part B. Flow of Examinees In HANES, the wide age range of sample persons, the large number of examinees sched- uled per day, and the fact that two different examinations are being carried out simul- taneously, necessitate an examinee flow scheme different from those used in earlier surveys. In Cycle I, schedules were staggered, with two examinees scheduled to begin at each half-hour interval. All went through the same fixed se- quence of examination elements. In Cycles II and III, six sample persons were scheduled for the beginning of each session and went through 28 one of three fixed sequences of examination elements according to a flow chart. The flow scheme used in HANES contains elements of both earlier systems. The usual workday consists of two sessions, with up to 10 examinations per session, eight nutrition exam- inees and two detailed examinees. The two detailed sample persons and five of the nutrition sample persons are scheduled for the beginning of a session. Three additional persons are sched- uled 1% hours later for the nutrition examina- tion. Scheduling is somewhat flexible to accom- modate situations when it is desirable that more than 10 persons be scheduled for a session and that persons be scheduled at times different from those normally used. This flexibility allows scheduling to be more responsive to the special problems of individual sample persons as well as to the conditions created by high or low response at a particular stand. A primary objective of this flow system is to reduce the time examinees are in the examina- tion center while using the examination staff in as efficient a manner as possible. The scheme gives a set of priorities by which examinees are assigned to the examination elements. However, these priorities do not require that an examinee receive one part of the examination before another if it means that he must wait for the first part because the examiner is busy. This basic scheme of assigning examinees was modi- fied by restrictions designed to meet operational requirements such as getting blood samples to the examination center laboratory in time to complete the laboratory work before the end of a session and insuring that examinees are seen by the ophthalmologist during a certain interval of time after receiving drops to dilate the pupils of their eyes. This system also incorporates recom- mended and maximum times for elements of the examination. For some elements of the examina- tion, two examiners are trained to routinely gather data. The assignment of examinees to these elements is controlled in such a way that the two examiners’ data can be compared statistically. When examinees arrive at the examination center, they are greeted by the nurse and the coordinator; the latter is a staff member with special responsibilities in the area of examinee flow and records preparation and review. As indicated by the flow system, soon after their arrival, examinees change from their street clothes into disposable examination uniforms designed to facilitate and standardize various elements of the examination such as the physi- cian’s examinations, body measurements, and X-rays. Physician and Nurse Examination The general physician’s examination is oriented toward gathering data on physical conditions pertinent to nutrition and certain chronic diseases, in contrast to the concept of a general clinical examination performed in the manner most familiar to the examining physi- cian. Before beginning examinations, each new physician spends from 1 to 3 days being trained by the HANES Nutrition Medical Advisor to recognize symptoms or conditions associated with nutritional deficiencies. This training is usually performed with ongoing children and youth projects supported by the Office of Economic Opportunity and in a Maryland State hospital with patients suffering from nutritional deficiencies secondary to underlying chronic conditions such as alcoholism. Additional train- ing is provided at the examination center with respect to the objectives of the detailed compo- nent of the physician’s examination just before the start of the regular examination. Each medical history questionnaire is re- viewed by the examining physician on the day before the scheduled examination. Special atten- tion is paid to any entries that suggest restric- tions on the examinee’s ability to participate in any tests or procedures, particularly the spirom- etry, single breath diffusing capacity, or X-rays, and to items that may require further followup in the course of the examination. All examinees receive a physical examination with emphasis on nutritional aspects. After monitoring the examinee’s sitting blood pressure and pulse, the physician examines the ears for any abnormalities and then the head, eyes, mouth, and neck (including the thyroid, figure 4), looking especially for lesions associated with nutritional deficiencies of vitamins A, B com- plex, and C, and minerals such as iodine and iron. While examining the chest (heart and lungs), an inspection is made of the chest and Figure 4. Physician's examination of the thyroid. back for signs of possible deficiencies of vita- mins A and D. The physician then palpates the abdomen, and in examinees over age 25, per- cusses the liver. The neurological and musculo- skeletal systems are evaluated by testing the deep tendon reflexes and neuromuscular excita- bility for stigmata of thiamine or mineral defi- ciencies, and by palpating and inspecting the skeleton for lesions associated with vitamin D or C deficiencies. The skin of the extremities is then inspected and palpated, particularly that of the thighs and upper outer arms, for lesions that might be associated with deficiencies of vitamins A, C, Bg, or essential fatty acids. Findings are recorded in two categories, those related and those not related to nutrition. A subjective impression is recorded on the nutritional status of the examinee based on the examination and the medical history. Venipuncture is done on all examinees by the nurse, either at the beginning of the derma- tologist’s examination or at some other con- venient time during the course of the examina- tion. It is performed in the dermatologist’s examining area by the nurse with the assistance of the dermatologist or, in certain instances, with the assistance of the examining physician. The examinees in the detailed component receive a more comprehensive cardiovascular evaluation and musculoskeletal examination. The cardiovascular evaluation includes a routine auscultation of the heart. If abnormal conditions are found, a tentative diagnosis is made along with an evaluation of the degree of severity and 29 the certainty of the diagnosis using a scale ranging from 0 to 9. In addition to the initial blood pressure reading taken at the beginning of the examination on all examinees, two more readings are taken by the nurse at the end of the physician’s examination—one with the examinee supine, and the other immediately after with the examinee sitting on the edge of the examination table. The musculoskeletal examination involves the recording of findings of abnormalities and various manifestations of the knees, hips, shoulders, elbows, wrists, phalanges, ankles, feet, and back. Detailed examinees also receive an examina- tion of the ears, nares, reticuloendothelial sys- tem, an arterial evaluation, and a tuberculin skin test. The ear examination is of special interest because of its relevance to the audiometric data. It consists of a general inspection of the external ear, and a routine otoscopic examination of the external auditory canals and tympanic mem- branes. The tuberculin skin test, which is admin- istered by the nurse, is read by her or another specially trained staff member between 48 and 72 hours later by having the examinee return to the examination center or by visiting his home. The test will be discontinued after the 35th HANES stand because of the burden imposed on the examinee and the field staff by the necessity of a second visit. At the end of the detailed examination by the physician, he administers appropriate supple- mental medical history questionnaires as re- quired, based on positive responses to certain items on the medical history questionnaires administered earlier in the home. These supple- ments are identified as Supplement A, Arthritis; Supplement B, Respiratory; and Supplement C, Cardiovascular. Ophthalmology Examination The ophthalmologic examination, with a few exceptions, is essentially the same for all exam- inees. It includes an ocular history regarding previously known eye disease or previous surgery; for examinees age 4 years and over a determination of monocular distance visual acu- ity with usual correction, if any, and with a pinhole test to determine correctability for those with acuity less than 20/20, prescription of 30 present glasses, slit lamp examination (figure 5), and retinoscopy for detailed examinees only with acuity less than 20/40; applanation tonom- etry on examinees age 20 years and over; maxillary sinus transillumination for detailed examinees only; and examination of the pupils as well as examination of the lids, globe, conjunctiva, sclera, cornea, anterior chamber, iris, and lens. The pupils are dilated in most instances for evaluation of the vitreous and retina. Diagnoses are recorded for the six most serious eye conditions found, with an indication for each of whether it affects vision and whether treatment is being given or needed. Ophthal- mologists from the National Eye Institute are responsible for verifying the resultant diagnoses and for other aspects of quality control in this area. The ophthalmology examination will be dis- continued after the first 35 HANES stands have been completed. This decision was arrived at by the National Eye Institute as a result of the problems encountered in recruiting ophthal- mologists to conduct the examinations and of the insufficient number of staff within the Institute to carry out the program adequately. It is felt, however, that the data collected from the first 35 stands will provide a basis for analysis of the data for the original purposes of the exami- nation. Dermatology Examination The dermatological examination is a complete clinical examination of the skin and its append- ages that considers normal variations in texture Figure 5. Ophthalmology examination. and color, certain manifestations of aging, and all pathological changes, documenting significant diagnoses by biopsy or culture whenever possi- ble. Estimates are made of actinic exposure experienced as well as actinic damage sustained, and of occupational risk from irritant and allergic contractants. For an examinee with a significant hand, foot, or generalized problem, a judgment is made about the burden to the examinee in terms of discomfort or disability, about the care sought, and about the effect expected from current best care. A lesion is photographed if there is some question about the diagnosis, if the lesion is in any way unique, or if it is to be biopsied. Dental Examination The dental examiners derive their findings uniformly by following a written set of objective standards in which they have been thoroughly trained. The standards are guidelines that, in effect, narrow the range of examiner variability by eliminating many of the borderline or ques- tionable conditions that are frequently a source of disagreement. To avoid other sources that might result in systematic bias, the dentist does not dry or isolate teeth, remove oral debris and calculus, or probe any tooth surface that does not have an overt sign of decay. The dentist dictates the condition of each tooth present to a trained recorder (health technician). The teeth are classified as sound, filled, decayed, filled-defective, and nonfunc- tional. Missing permanent teeth are classified under one of the following four categories: unerupted, carious extraction, accidental loss, and orthodontic extraction. When missing teeth are replaced on a fixed or partial denture, the tissue under the replacement as well as the replacement itself, is rated. When no natural teeth remain in the jaw, the condition of the jaw and the status of the artificial replacement, when present, are recorded. The next step of the examination is an assessment of the periodontal structures and the status of oral hygiene. The Periodontal Index is employed to assess the presence or absence of periodontal disease. By this system of classifi- cation, scores are assigned according to the extent of gingival inflamrnation, the presence or absence of periodontal pockets, and the firmness of a tooth in its socket. To assess oral hygiene, scores are recorded for all or any of six predesignated teeth that are present. The scores indicate the amount of debris and the amount of calculus on selected surfaces. Fluoride and non- fluoride opacities and other conditions such as bleeding gums, diffuse marginal inflammation, swollen red papillae, and recession are also recorded. The occlusion of all persons age 6-21 years is appraised by a series of counts and measure- ments. Anteroposterior position of the lower jaw in relation to the upper jaw is recorded. Counts are made of teeth in crossbite and teeth that are malaligned. Measurements are made in the anterior area of the jaws of overjet, man- dibular protrusion, overbite, and openbite. An enamel biopsy is taken on persons who have a natural upper incisor present with a front surface free of cavities and fillings. The enamel sample is “polished off” from an area about one-eighth of an inch in diameter and to a depth of approximately .0002 inch. This is about as much enamel as is removed during a routine prophylaxis by a dentist or dental hygienist. The sample is analyzed to determine the fluoride content of the tooth from which it was re- moved. The result, expressed in parts per million, will be compared with the number of cavities and fillings on selected tooth surfaces to assess the relationship between fluoride content and the occurrence of dental caries. The dental examiner, using his best clinical judgment, estimates the dental treatment re- quired for every sample person. In so doing, he takes into consideration the status of oral hygiene and periodontal disease, the quantity and quality of past dental care, the responses to questions asked at the beginning of the examina- tion about chewing and eating difficulties, the age of the individual, and the probable benefit of each specific treatment plan to the individ- ual’s health and nutrition. The treatment recom- mendation may include any procedure ranging from a simple filling to extraction of all remain- ing teeth and denture construction. At the close of the examination, the dental examiner makes a brief oral report to the examinee about the status of his oral health. It is always stressed that the survey examination 31 should not be considered as a substitute for a regular dental checkup. A report of findings is mailed, as described in a previous section. Dietary Interview The dietary interview is conducted by HANES personnel with minimum qualifications of a Bachelor’s degree in food and nutrition. Most, however, are registered dietitians with experience in dietary interviewing. With some exceptions, interviews are conducted in small private rooms in the MEC. A small number of persons scheduled for the detailed examination may be visited in their homes. Home visits are sometimes required if the mother or other person responsible for a child’s regular feeding does not accompany him to the examination center. The 24-hour Dietary Recall Question- naire is administered for the total day before the day of examination (figure 6). Fifty-one three- dimensional food portion models are used as a guide in conducting the interview to help the sample person to estimate the amounts of various foods consumed. This questionnaire is followed by the Dietary Frequency Question- naire that obtains information about how often certain foods have been eaten during the pre- ceding 3 months. Foods reported in the 24-hour Dietary Recall Questionnaires are later coded by Figure 6. Dietary interview. 32 the interviewers using nutrient information from the U.S. Department of Agriculture Handbook No. 8. Other food codes used are from the Tulane University’s master dietant list, from Bowes and Church’s Food Values of Portions Commonly Used,86 or from USDA House and Garden Bulletin No. 72, and commercial sources. All dietary data will be analyzed by a computer program based on nutrient data for 100-gram portions of foods. Following administration of the dietary ques- tionnaires, the interviewers are also responsible for the completion of the Health Care Needs Questionnaire and the General Well Being Ques- tionnaire for all examinees in the detailed component. While the first of these is inter- viewer administered, the second is intended to be essentially self-administered. Laboratory Procedures The laboratory technician is responsible for screening a urine specimen from each examinee for sugar, albumin, and blood; for performing the basic hematology tests; and for preparing and packaging all blood and urine samples to be sent to the CDC for analysis (figure 7). The basic hematology performed in the MEC for each examinee, if sufficient specimen is available, is hemoglobin, hematocrit, and red and white cell counts. Sedimentation rates are determined and a smear for differential W.B.C. count is also prepared. All hematology tests are performed in duplicate, and all results are recorded on a daily worksheet. All clinically borderline results are repeated immediately. Once it is ascertained that a particular result is abnormal according to CDC guidelines, it is reported directly to the HANES examining physician for any necessary followup. With the exception of the T-3 and T-4 deter- minations, which are performed by a private contractor, the remaining laboratory determina- tions, listed in an earlier section, are performed by CDC (figure 8). Health Technician Procedures Two technicians conduct the following parts of the examination on all examinees: measure- ment of height and weight, a series of body and Figure 8. CDC Nutrition Laboratory. 33 skinfold measurements, and X-rays of the hand and wrist of examinees 1-17 years of age. In addition, these technicians are also responsible for conducting the following on all examinees in the detailed component of the survey: an audiometric test, spirometry, electrocardiogram, single breath diffusing capacity, goniometry, and X-rays of the chest, hand and wrist, hips, and knees. Audiometric testing of detailed examinees is done in a specially constructed, acoustically treated room built into one of the trailers in each of the mobile examining units. The room is designed to provide sufficient sound attenuation for pure tone testing at frequencies of 250-6,000 Hz to at least as low as -20-dB relative to audiometric zero (International Standardization Organization, 1964) in the presence of the degree of external noise usually present during the course of the examinations at the various locations. Each adult is tested at the following four frequencies: 500, 1,000, 2,000, and 4,000 Hz, with the 1,000-Hz frequency repeated a second time. Air-conduction tests for both ears are completed first, then the bone-conduction tests in the order indicated on the recording form. Alternation of presentation to each ear varies among examinees with the testing started in the right ear when the examinee’s sample number is odd and in the left ear when even. The threshold recorded for each frequency is the lowest decibel level at which 50 percent or more of the responses are obtained, that is, in two out of three or three out of five trials. Masking for the nontest ear is done in air-conduction testing only on retest when there is a 40-dB difference or more in the thresholds for the two ears. In bone-conduction testing, masking is done rou- tinely in the nontest ear at 30, 40, and 50 dB above threshold for that ear. Standardized test- ing procedures are used to insure as consistent test results as possible throughout the survey. Any condition such as earache, cold, or other problem that might affect the test results is also recorded. All detailed examinees are given a 12-lead electrocardiogram and spirogram with results recorded on magnetic tape using a Beckman Digicorder. Under terms of an agreement with the George Washington University School of 34 Medicine, Washington, D.C., the tapes are for- warded to their facilities for processing. For each examinee, HANES is provided with tabular printouts and digital computer tapes of all basic data. For the electrocardiogram, these data consist of the amplitudes and durations of various waves in each of the 12 leads, as well as such data as QRS and T axes, and rates. Basic data for the spirogram consist of measurements from five trials of maximal forced expiratory volume, the forced expiratory volumes at %2, %, 1, 2, and 3 seconds, and flow rates including the maximum expiratory, the maximum midexpira- tory, and the maximum terminal (figure 9). The single breath carbon monoxide diffusion studies are performed on detailed examinees on a Collins modular lung analyzer machine with a digital readout module. Basic data are provided from which computations can be made of the diffusion of gases across the pulmonary mem- branes. In addition to compiling much-needed normative data on carbon monoxide diffusion, the test also identifies individuals with pul- monary deficiencies. These data will comple- ment other HANES pulmonary data such as chest X-rays, spirometry, and respiratory history. Examinees in the age range of 1-17 years are given routinely an X-ray of the hand-wrist for bone age and density (figure 10). This X-ray is an 8 X 10 film taken at a distance of 36 inches. No other X-rays are made of nutrition exam- inees except in those few instances where an X-ray of the chest is indicated as an aid to a diagnosis by the physician. Detailed examinees, Figure 9. Spirometry. Figure 10. Hand and wrist X-rays. however, do receive the chest X-ray routinely. Two 14 X 17 films are taken at a distance of 72 inches—one a PA film and the other a lateral film. In addition, detailed examinees also receive X-rays of the hips, knees, and hand-wrist. The hip and the knee X-rays are both 14 X 17 films; the former is taken at a distance of 72 inches and the latter is an anteroposterior film of both knees at 40 inches. The hand-wrist is an 8 X 10 film taken at a distance of 36 inches. Certain precautions are taken to protect exami- nees as well as technicians. Females between the ages of 12 and 45 are carefully screened so that those pregnant will not be X-rayed, and no female under the age of 50 is given an X-ray of the hip. To minimize radiation hazard, use is made of a special “no scatter” cone, of lead- rubber apron shields, and of radiation badges that are provided at the beginning of testing in each location for each technician to wear. Periodic dosimetry field surveys are conducted by the Radiological Health Division of the PHS. All films, except the hand-wrist X-ray of the detailed examinees, are developed and reviewed so that unsatisfactory films can be repeated before the examinees leave the examination center. Goniometry measurements are taken on all detailed examinees to determine the range of motion of certain joints, the hip, and the knee. Specifically, 16 measurements are taken involv- ing the extension, flexion, abduction, adduction, both internal and external rotation of both hips, and the extension and flexion of the knees. This procedure will be discontinued after the 35th HANES stand to shorten the length of the examination time and because of problems encountered in the reproducibility of the data. In addition to height and weight measure- ments and a determination of handedness, six other body measurements are made of all examinees. These include elbow breadth, upper arm girth, triceps and subscapular skinfolds (figure 11), bitrochanteric breadth, and sitting 4 Figure 11. Taking skinfold measurements. 35 height. Children 1-7 years of age are also measured for head and chest circumferences. Chest circumference measurements of full inspi- ration and expiration are also made on all examinees in the detailed part of the examina- tion. QUALITY CONTROL The efforts of the quality control program extend to all phases of the operation—from the beginning of the Census interview until all collected data have been coded, edited, and placed on magnetic tape for computer use. The goal of the program is to assure that the national estimates of the various characteristics collected by the survey represent data of the highest attainable accuracy and precision within the limitation imposed by reasonable procedures and costs. A report concerning quality control activities in previous HES cycles has been published 87 In HANES, as in all sample surveys, there are two sources of error to be considered—sampling error and nonsampling error. Sampling error, that is, error due to making measurements on a sample rather than on the entire population, can be quantified and is the concern of all statisti- cians in sample survey design and in analysis. During the data-collection phase, problems due to this type of error are minimal. The non- sampling error is of constant concern during the data-collection phase and considerable attention, time, and effort of the HANES personnel are devoted to minimizing and measuring this type of error. One type of nonsampling error that can occur in voluntary surveys such as HANES is the bias introduced by nonresponse if the nonrespond- ents differ from the respondents with respect to the measurements being made. In past HES cycles and in the present HANES, a sample person is not considered a respondent unless he 1s actually examined, even though he may have completed several questionnaires during initial interviews. Past HES samples and the present HANES sample are defined at the time of the first household interview. Consequently, there is a certain amount of built-in nonresponse since persons who move, go on vacation, become ill, or for other reasons are not physically available 36 cannot be examined. If nonrespondents differ from respondents for a given measurement, the amount of nonresponse bias introduced into an estimate generally would be expected to vary with the amount of nonresponse. Therefore, response rates for a survey such as HANES are important as indicators of possible nonresponse biases. Response rates for Cycles I, II, and III were 87, 96, and 90 percent, respectively. These high response rates may be attributed to various methodological studies, to advance planning and publicity, to much diligent work by the health examination representatives, and to proper handling of examinees by the entire staff as well as, in Cycles II and III, to the age of the population segment sampled. The response rate in HANES at the time of preparation of this report had not been as high as in the earlier cycles, and the final rate will be lower than those obtained previously. Concern over the lower response rate and its - possible implications resulted in a study con- ducted in conjunction with the ongoing survey in the San Antonio, Texas, stand to determine the effect of remuneration on response. Half of the 600 sample persons were told during the HER interview that they would receive $10 after the examination, while no mention of remunera- tion was made to the other half. All who were examined, however, received payment after the examination. The study design also controlled on family income, number of housing units per segment, and the HER assignments. The findings of the study showed a response rate 12 percent higher in the group of sample persons offered the remuneration. As a result, payment of $10 is now being offered routinely to all sample persons if they participate in the examination. A report describing the methodology and findings of the study is currently being prepared for publication. Another type of nonsampling error that is of great concern in the quality control program is the measurement error that inevitably occurs during the examination procedure. Its impor- tance is easily recognized when it is considered that, in the present survey, each sample person represents approximately 7,500 persons; there- fore, any blemish on the survey findings for a particular person is greatly enlarged in the final analysis of the larger universe. Not only is it important to control and minimize this error, but it is equally important to measure, wherever possible, the amount of error. In HANES, several procedures are relied upon to accomplish these objectives. Before the col- lection of data, it was necessary to define precisely what is to be measured and to obtain instruction as to how the measurement should be performed. Advisors, both from within the staff of HANES and from outside sources, were instrumental in constructing the necessary defi- nitions and instructions, which were later incor- porated into a staff instruction manual covering all procedures. Intensive specialized training is given to each examination staff member in the specific procedures performed by them in the survey. The special advisors within HANES provide training in their respective areas while additional training in other areas is obtained from various outside sources. Although precise definitions and good initial training are necessary, they are generally not sufficient in a lengthy survey as HANES. The time factor creates a problem that does not occur when data are gathered in a short period of time. It is important to be consistent through- out the entire survey. In order to achieve consistency, in addition to providing the de- tailed written instructions on all aspects of the examination, the forms are structured, and periodic retraining is provided. Retraining time may range from a few minutes for a single item up to several days for an entire area, such as body measurements. In further efforts to attack measurement error, mechanical equipment is used wherever feasible to obtain a “hard document.” Em- ployed for this purpose are such devices as tape recorders, automatic recording of weight, photo- graphs of height, X-rays, and the recording of spirometry and electrocardiograms on magnetic tape. The reading and interpretation of the records so obtained can be done independently more than once. The use of instruments for measuring as well as for recording introduces another source of possible variation; thus, sys- tematic calibration is necessary. All instruments are calibrated at the beginning of each stand and also periodically throughout the stand, some before each examination. In some instances—for example, audiometers—resources are not avail- able in the examining center and machines must be sent away for calibration. Other instruments also receive periodic maintenance and service through special contract arrangements with the manufacturers. Environment is another important factor in achieving valid and standardized data. Good lighting, heating, and air conditioning are essen- tial. For example, it is very important to be able to standardize the light conditions under which the ophthalmology examination is given. Simi- larly, it is essential that the room in which the hearing test is given be soundproof. The subject being examined can also intro- duce error into the measurement. If the exami- nee fails to stand up straight for a height measurement, is uncooperative during the spirometry examination, or does not understand the directions given for the audiometry test—to give only a few examples—error will occur. It is, therefore, very important that staff members be aware of such possibilities and see that the examinee fully understands what he is to do and that his fullest cooperation is obtained. Despite precautions, there are biases and variable measurement errors that cannot be or are not judged important enough to be elim- inated. Another objective of the quality control program, therefore, is the determination of the total effect of these errors. For certain parts of the examination performed by the health techni- cian, the assignment of examinees is controlled so that the relative bias of individual technicians can be monitored. The collection of replicate data provides another means for evaluating measurement errors. Replicate data are obtained basically in two ways: by reevaluating or reread- ing a hard document or by reproducing an actual measurement, either by the usual procedure or by another standard procedure. Although hard documents such as the weight and height meas- urements are reevaluated, the replicate program is primarily concerned with reproducing actual measurements. During the actual operation of the survey, the primary use of replicate data is in indicating areas where retraining or reevaluation of proce- dures is needed. When the reports of findings of the survey are published, data from the repli- cates will be used to apprise the reader of the extent to which the data may be affected by 37 measurement error and to call his attention to this problem. Replicate data are gathered in many specific areas of the examination with varying degrees of frequency. For example, replicate measurements are made on every examinee for measurements such as spirometry and hematocrit. Ophthal- mologists from the NEI independently replicate the complete ophthalmic examination on all the first day’s examinees for each test stand after the examiner is trained in the survey technique. The dental advisors systematically replicate the field examiners on a subsample of examinees for the purpose of surveillance and on-the-spot retraining. They also periodically replicate one another. Although replicates are performed for a different purpose, the data are preserved and in previous HES surveys have proved useful for indicating the extent of error in final evalua- tions. Additional blood is drawn from a system- atic subsample of detailed examinees for the purpose of replicating thyroid hormone determi- nations. Comparisons are made upon receipt of results and have been valuable as the basis for corrective action. This type of replicate will also be used in the final evaluation of measurement process error. Several measures are taken to assure com- pleteness and consistency in the recording proc- ess. All questionnaires are reviewed for omis- sions and inconsistencies. With the exception of the questionnaires completed in the examining center, all are reviewed by personnel in the field management office. If errors are noted, correct information is obtained by phone or from the examinee when he comes in for the examina- tion. Errors in recording body measurements, goniometry, and results of the dental examina- tion are reduced by having a second person act as a recorder. In addition, all data gathered in the. examining center are reviewed by the exam- ination staff before the examinees leave. All Dietary, 24-Hour Recall and Food Frequency Questionnaires are coded by the interviewer in the field and are checked by another interviewer before being forwarded to headquarters. At each location, each dietary interviewer records two complete interviews on randomly selected sample persons. The resulting taped interviews are critiqued for adherence to established guide- lines, procedures, and policies by an inde- 38 pendent contractor experienced in the art of dietary interviewing. PLANS FOR ANALYSIS AND PUBLICATION OF DATA Because the data collection operation of the nutrition component in the HANES program will take about 2% years to complete, the sample and schedule designs have been arranged so that it will be possible to do some preliminary analysis of certain portions of the nutrition component before that time. Of the total 65 PSU’s in the survey, a subset of 35 was selected carefully so as to be representative of the whole. These are scheduled for completion in October 1972, and the first preliminary analyses will be available in early calendar year 1973. All data from the subset will be statistically weighted and nonresponse adjusted so as to represent closely the total U.S. population with respect to age, race, sex, and several other variables. Because of the small sample size, the preliminary reports will be unable to provide some of the detailed subclassifications of the data, such as region or urbanization. More detailed breakdowns of the data will be available in the analysis of the 65 PSU’s. The first of these reports as related to nutrition is scheduled for mid-1974. The data for the first 35 sampling units will be reported in four primary categories with a necessarily limited content as follows: Report Category Contents Distribution of selected nutri- ents reported on the Dietary 24-hour Recall Questionnaire and percent of individuals not meeting recommended nutri- ent allowances. Dietary intake data ....... Distributions of selected nutri- tionally related test results and percent of individuals below specified levels. Distributions of selected nutri- tionally related measurement data by population groups with some comparative norma- tive data from earlier DHES programs. Hematological and biochemical test results ees ee seen Anthropometric data ...... Report Category Contents Prevalence of selected condi- tions as stigmata of nutritional deficiency by population groups. Nutritional findings from the physician’s examination . A final completion date for the collection of data of the detailed component has not been firmly established at the time of this writing, primarily because the unknown sample sizes of future PSU’s affect scheduling. Based on the design of the survey, a complete cycle (for at least many parts of the detailed component) encompasses two of the nutrition cycles, or about 130 PSU’s. REFERENCES National Center for Health Statistics: Origin, program, and operation of the U.S. National Health Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 1. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1963. 2National 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. 3U.S. National Health Survey: A study of special purpose medical-history techniques. Health Statistics. PHS Pub. No. 584-D1. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1960. 4U.S. National Health Survey: Attitudes toward cooperation in a health examination survey. Health Statistics. PHS Pub. No. 584-D6. Public' Health Service. Washington. U.S. Government Printing Office, July 1961. 5U.S. National Health Survey: Evaluation of a single-visit cardiovascular examination. Health Statistics. PHS Pub. No. 584-D7. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1961. 6National Center for Health Statistics: Comparison of two vision-testing devices. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 1. Public Health Service. Washington. U.S. Government Printing Office, June 1963. "National Center for Health Statistics: The one-hour oral glucose tolerance test. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 3. Public Health Service. Washington. U.S. Government Printing Office, July 1963. 8National Center for Health Statistics: Cooperation in health examination surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 9. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 9National Center for Health Statistics: Replication, an approach to the analysis of data from complex surveys. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 14. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1966. 10National Center for Health Statistics: Three views of hypertension and heart disease. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 22. Public Health Service. Washing- ton. U.S. Government Printing Office, Mar. 1967. National Center for Health Statistics: Factors related to response in a health examination survey, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 2-No. 36. Public Health Service. Washington. U.S. Govern- ment Printing Office, Aug. 1969. 12National Center for Health Statistics: Cycle I of the Health Examination Survey sample and response, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 1. Public Health Service. Washington. U.S. Govern- ment Printing Office, Apr. 1964. National Center for Health Statistics: Glucose tolerance of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 2. Public Health Service. Washington. U.S. Government Printing Office, May 1964. National Center for Health Statistics: Binocular visual acuity of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 3. Public Health Service. Washington. U.S. Government Printing Office, June 1964. 15National Center for Health Statistics: Blood pressure of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 4. Public Health Service. Washington. U.S. Government Printing Office, June 1964. 16National Center for Health Statistics: Blood pressure of adults by race and area, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 5. Public Health Service. Washington. U.S. Government Printing Office, July 1964. "National Center for Health Statistics: Heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 6. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1964. 18National Center for Health Statistics: Selected dental findings in adults by age, race, and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 7. Public Health Service. Washington. U.S. Govern- ment Printing Office, Feb. 1965. 19National Center for Health Statistics: Weight, height, and selected body dimensions of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series- 11-No. 8. Public Health Service. Washington. U.S. Government Printing Office, June 1965. 39 20National Center for Health Statistics: Findings on the serologic test for syphilis in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 9. Public Health Service. Washington. U.S. Government Printing Office, June 1965. 21National Center for Health Statistics: Coronary heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 10. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1965. 22National Center for Health Statistics: Hearing levels of adults by age and sex, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 11. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1965. 23National Center for Health Statistics: Periodontal disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 12. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1965. 24National Center for Health Statistics: Hypertension and hypertensive heart disease in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 13. Public Health Service. Washington. U.S. Government Printing Office, May 1966. 25National Center for Health Statistics: Weight by height and age of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 14. Public Health Service. Washington. U.S. Government Printing Office, May 1966. 26National Center for Health Statistics: Prevalence of osteo- arthritis in adults by age, sex, race, and geographic area, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 15. Public Health Service. Washington. U.S. Government Printing Office, June 1966. 27National Center for Health Statistics: Oral hygiene in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 16. Public Health Service. Washington. U.S. Government Printing Office, June 1966. National Center for Health Statistics: Rheumatoid arthritis in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 17. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. National Center for Health Statistics: Blood glucose levels in adults, United. States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 18. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. National Center for Health Statistics: Age at menopause, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 19. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1966. INational Center for Health Statistics: Osteoarthritis in adults by selected demographic characteristics, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 20. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 32National Center for Health Statistics: Childbearing and diabetes mellitus, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 21. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1966. 40 33National Center for Health Statistics: Serum cholesterol levels of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 22. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1967. 34National Center for Health Statistics: Decayed, missing, and filled teeth in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 23. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1967. 35National Center for Health Statistics: Mean blood hemato- crit of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 24. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1967. 36National Center for Health Statistics: Binocular visual acuity of adults by region and selected demographic charac- teristics, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 25. Public Health Service. Washington. U.S. Government Printing Office, June 1967. National Center for Health Statistics: Hearing levels of adults, by race, region, and area of residence, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 26. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1967. 38National Center for Health Statistics: Total loss of teeth in adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 27. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1967. 9National Center for Health Statistics: History and examina- tion findings related to visual acuity among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 28. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1968. 4ONational Center for Health Statistics: Osteoarthritis and body measurements. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 29. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1968. 41National Center for Health Statistics: Monocular-binocular visual acuity of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 30. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1968. 2National Center for Health Statistics: Hearing levels of adults, by education, income, and occupation, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000- Series 11-No. 31. Public Health Service. Washington. U.S. Government Printing Office, May 1968. 43National Center for Health Statistics: Hearing status and ear examination: findings among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 32. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1968. National Center for Health Statistics: Selected examination findings related to periodontal disease among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 33. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1969. 45National Center for Health Statistics: Blood pressure as it relates to physique, blood glucose, and serum cholesterol, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 34. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1969. 46National Center for Health Statistics: Skinfolds, body girths, biacromial diameter, and selected anthropometric indices of adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 35. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1970. 47National Center for Health Statistics: Need for dental care among adults, United States, 1960-1962. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 36. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1970. 48National Center for Health Statistics: Selected symptoms of psychological distress, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 37. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1970. 49National Center for Health Statistics: Parity and hyper- tension. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1024-Series 11-No. 38. Public Health Service. Washington. U.S. Government Printing Office, Mar, 1972. 50National Center for Health Statistics: Plan, operation, and response results of a program of children’s examinations. Vital and Health Statistics. PHS Pub. No. 1000-Series 1-No. 5. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1967. INational Center for Health Statistics: Evaluation of psycho- logical measures used in the Health Examination Survey of children ages 6-11. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 15. Public Health Service. Washington. U.S. Government Printing Office, Mar, 1966. 52National Center for Health Statistics: Calibration of two bicycle ergometers used by the Health Examination Survey. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 21. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1967. 53National Center for Health Statistics: A study of the achievement test used in the Health Examination Surveys of persons aged 6-17 years. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 24. Public Health Service. Washington. U.S. Government Printing Office, June 1967. 54National Center for Health Statistics: Orthodontic treat- ment priority index. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 25. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1967. 55National Center for Health Statistics: Sample design and estimation procedures for a national health examination survey of children. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1005-Series 2-No. 43. Public Health Service. Wash- ington, U.S. Government Printing Office, Aug. 1971. 6National Center for Health Statistics: Subtest estimates of the WISC full scale IQ’s for children. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1047-Series 2-No. 47. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1972. 57National Center for Health Statistics: Visual acuity of children, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 101. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1970. 58National Center for Health Statistics: Hearing levels of children by age and sex, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 102. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1970. 59National Center for Health Statistics: School achievement of children 6-11 years as measured by the reading and arithmetic subtest of the Wide Range Achievement Test, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 103. Public Health Service. Washington. U.S. Government Printing Office, June 1970. 60National Center for Health Statistics: Height and weight of children, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 104. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1970. 61National Center for Health Statistics: Intellectual maturity of children as measured by the Goodenough-Harris drawing test, United States. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 105. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1970. 2National Center for Health Statistics: Decayed, missing, and filled teeth among children, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1003-Series 11-No. 106. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1971. 63National Center for Health Statistics: Intellectual develop- ment of children as measured by the Wechsler Intelligence Scale, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1004-Series 11-No. 107. Public Health Service. Wash- ington. U.S. Government Printing Office, Aug. 1971. 64National Center for Health Statistics: Parent ratings of behavior patterns of children, United States. Vital and Health Statistics, DHEW Pub. No. (HSM) 72-1010-Series 11-No. 108. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1971. National Center for Health Statistics: School achievement of children by demographic and socioeconomic factors, United States. Vital and Health Statistic. DHEW Pub. No. (HSM) 72-1011-Series 11-No. 109. Public Health Service. Washington. U.S. Government Printing Office, Nov. 1971. 66National Center for Health Statistics: Intellectual develop- ment of children by demographic and socioeconomic factors, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1012-Series 11-No. 110. Public Health Service. Wash- ington. U.S. Government Printing Office, Dec. 1971. 67National Center for Health Statistics: Hearing levels of children by demographic and socioeconomic characteristics, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1025-Series 11-No. 111. Public Health Service. Wash- ington. U.S. Government Printing Office, Feb. 1972. National Center for Health Statistics: Binocular visual acuity of children: demographic and socioeconomic charac- teristics, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1031-Series 11-No. 112. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1972. 9National Center for Health Statistics: Behavior patterns of children in school, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1042-Series 11-No. 113. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1972. 7ONational Center for Health Statistics: Hearing sensitivity and related medical findings among children, United States. Vital and Health Statistic. DHEW Pub. No. (HSM) 72-1046-Series 41 11-No. 114. Public Health Service. Washington. U.S. Govern- ment Printing Office, Mar. 1972. National Center for Health Statistics: Eye examination findings among children, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1057-Series 11-No. 115. Public Health Service. Washington. U.S. Government Printing Office, June 1972. 2National Center for Health Statistics: Intellectual maturity of children: demographic and socioeconomic factors, United States. Vital and Health Statistic. DHEW Pub. No. (HSM) 72-1059-Series 11-No. 116. Public Health Service. Washington. U.S. Government Printing Office, June 1972. 3National Center for Health Statistics: Periodontal disease and oral hygiene among children, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1060-Series 11-No. 117. Public Health Service. Washington. U.S. Government Printing Office, June 1972. 4National Center for Health Statistics: Color vision defi- ciencies in children, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1600-Series 11-No. 118. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1972. 5National Center for Health Statistics: Height and weight of children: socioeconomic status, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1601-Series 11-No. 119. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1972. 76National Center for Health Statistics: Skinfold thickness of children 6-11 years, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1602-Series 11-No. 120. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1972. 77National Center for Health Statistics: Relationship among parent ratings of behavioral characteristics of children, United States. Vital and Health Statistic. DHEW Pub. No. (HSM) 73-1603-Series 11-No. 121. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1972. 78National Center for Health Statistics: Hearing and related medical findings among children: race, area, socioeconomic differentials, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1604-Series 11-No. 122. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1972. 79National Center for Health Statistics: Selected body meas- urements of children 6-11 years, United States, 1963-65. Vital 42 and Health Statistics, DHEW Pub. No. (HSM) 73-1605-Series 11-No. 123. Public Health Service. Washington. U.S. Govern- ment Printing Office, Feb. 1973. 80National Center for Health Statistics: Height and weight of youths 12-17 years, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1606-Series 11-No. 124. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1973. 81National Center for Health Statistics: Prenatal-postnatal health needs and medical care of children, United States. Vital and Health Statistics. DHEW Pub. No. (HSM) 73-1607-Series 11- No. 125. Public Health Service. Rockville, Md. In preparation. 82National 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 Pub. No. 1000-Series 1-No. 8. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1969. 83National Center for Health Statistics: Development of the brief test of literacy. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 27. Public Health Service. Washington. U.S. Government Printing Office, Mar. 1968. 84National Center for Health Statistics: Comparison of timed and untimed presentation of the Goodenough-Harris Test of Intellectual Maturity. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 35. Public Health Service. Washington. U.S. Government Printing Office, June 1969. 85National Center for Health Statistics: Loudness balance study of selected audiometer earphones. Vital and Health Statistics. PHS Pub. No. 1000-Series 2-No. 40. Public Health Service. Washington. U.S. Government Printing Office, Dec. 1970. 86 Church, C. F., and Bowes, H. N.: Bowes and Church’s Food Values of Portions Commonly Used. Philadelphia. Lippincott, 1966. 87 National Center for Health Statistics: Quality Control in a national health examination survey. Vital and Health Statistics. DHEW Pub. No. (HSM) 72-1023-Series 2-No. 44. Public Health Service. Washington. U.S. Government Printing Office, Feb. 1972. 88Goodman, R., and Kish, L.: Controlled selection—a tech- nique in probability sampling. J.Am.Statist.A. 45(251):350-373, Sept. 1950. APPENDIX | TECHNICAL NOTES ON THE SAMPLE DESIGN Definition of Terms Standard metropolitan statistical area (SMSA).—SMSA consists of a county or group of contiguous counties (except in New England) that contains at least one central city of 50,000 people or more, or “twin cities” with a com- bined population of at least 50,000 population. In addition, other contiguous counties are in- cluded in SMSA if, according to certain criteria, they are socially and economically integrated with the central city. Definitions of SMSA’s that identify the composition and structure of each are given in an Office of Management and Budget publication, Standard Metropolitan Sta- tistical Areas, 1967 edition. Geographic regions.—For purposes of the Health Examination Survey, the 48 contiguous States and the District of Columbia are divided into four regions of about the same population size. The regions and their composition are as follows: Region States Included Northeast . . Pennsylvania, New Jersey, Con- necticut, Rhode Island, Massa- chusetts, New York, Vermont, New Hampshire, Maine Midwest Ohio, Michigan, Indiana, Illinois, Wisconsin, Minnesota, Iowa, Missouri South Delaware, Maryland, Virginia, West Virginia, Kentucky, Arkan- sas, Tennessee, North Carolina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, District of Columbia Washington, Oregon, Idaho, Montana, Wyoming, Colorado, Utah, Nevada, California, Ari- zona, New Mexico, Texas, Okla- homa, Kansas, Nebraska, South Dakota, North Dakota 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.?388 The control variables used for this sample design are ‘“‘State groups” and “rate of population change,” that are defined as follows: State groups. Separate groups were formed within geo- graphic regions, as shown in table I. To form the State groups, the Health Interview Survey (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. Rate of population change. Groups were defined differently for each region as indicated in table II. In the Northeast Region, for example, PSU’s with less than a 3-percent increase in population between 1950 and 1960 were classified in group 1, while this class in the Midwest Region included only those PSU’s with a loss or with no gain in population. 43 Table |. State groups by geographic region Region State group number States in group INOPINBBSE cso tv vino w i5i nn ia ime 3 nm wn iw om me im ikon 1 New York. 2 Pennsylvania and New Jersey. 3 Maine, New Hampshire, Vermont, Massachusetts, Con- necticut, and Rhode Island. Midwest .............cciiiiiinnnnnnnnnn 1 Ohio. 2 Michigan. 3 Indiana and Illinois. 4 Missouri. 5 Kansas, Nebraska, lowa, and North Dakota. 6 Wisconsin and Minnesota. SOU «vu nvvsnmws sumossmsnmmmsmanssdsess 1 Maryland, Delaware, and District of Columbia. 2 Virginia and West Virginia. 3 Kentucky and Tennessee. 4 North Carolina and South Carolina. 5 Georgia. 6 Alabama and Mississippi. 7 Florida. 8 Arkansas, Louisiana, and Texas. VBSY fe. 205 eo: wr aioe wt wo at 07s alm: wn mh wi Tr 2 32 3 Ee 1 California and Nevada. 2 Texas. 3 Washington, Oregon, Idaho, and Montana. 4 Oklahoma, Arkansas, and Louisiana. 5 Wyoming, Utah, Colorado, New Mexico, and Arizona. 6 North Dakota, South Dakota, Nebraska, Kansas, Minnesota, and Missouri. Table Il. Ranges for rate-of-population-change control groups by geographic region Region Rate-of-population-change group number Northeast Midwest South West Percent population change, 1950-60 Tonio ow vinm pe 2 ER RE EE ER AB 8 A RE 8 Re 3 and under | Oand under | —10 and under | —5 and under 2 nei RE SE SER REE ER SL mW ke Be 5-11 1-15 -9-0 -20 BS NRE SR RE 016 6 He 0 0 el A 12-23 16-23 1-8 4-21 4 3 He (200 TA aR) oR 00 onal 0 yk om oo ov i es reer i 02 0 4 25-58 24-30 9-16 24-39 EL v1 915s Sk Winkie a Sen te 6 wie aT wit ier § Tar STD 0 Bw ie EE EE 1 - 34-81 19-26 40-59 BS res wie PE EE VRE OE RAE Re Se Sa a - - 27-36 73-167 Z come PRE RE SEER SEE RE ERE RR eek eee - - 3747 - Bi 5 inns RE EE Be AE Red - - 50-301 - 44 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 as shown in table 1 in the text of this report. 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 purposes. Current poverty areas.>—Poverty areas were originally defined on the basis of 1960 census data in the 100 largest metropolitan areas. They were determined by ranking census tracts in places with a 1960 population of 250,000 or more, according to the relative presence of each of the following equally weighted poverty-linked characteristics: (1) family income below $3,000, (2) children in broken homes, (3) persons with low educational attainment, (4) males in un- skilled jobs, and (5) substandard housing. Those tracts falling in the lowest quartile of the ranking were defined as poor tracts and further adjusted for contiguity and minimum size in order to approximate areal concentrations of poverty. The ‘“‘current poverty areas” are de- fined similarly, based on a detailed investigation made by local metropolitan officials and the Census Bureau in 1970 in these places with population of 250,000 people or more. In general, census tracts were deleted from the list of poverty areas if local officials sug- gested deletion and if (1) the combined (five- factor) ranking of the tract fell in the highest quartile of “poor” tracts in 1960, (2) the com- bined ranking of the tract fell in the other three quartiles of poor tracts in 1960 but the income rank fell in the highest quartile, or (3) the 1960 population of the tract was less than 1,000 regardless of its rank, on the assumption that major changes could have taken place within it since 1960. Tracts originally classified as poverty areas were not included as current poverty areas when substantial urban renewal or other major improvements in housing conditions had taken 3Arno I. Winard, unpublished paper, U.S. Bureau of the Census. place within them. Also, any “nonpoor” tract that was originally included in the 1960 poverty area because it was completely surrounded by poor tracts was deleted. Census tracts were added as poverty areas as suggested by local officials and if (1) 1959 median family income of the tract was below $6,000, (2) the 1959 median family income of the tract was between $6,000 and $7,000 and its most recent welfare recipient or illegitimacy rates ranked in the lowest two quintiles within the city, or (3) when the 1959 median family income of the tract was $7,000 or more and it ranked in the lowest quintile of the charac teristics cited above or if a specific written explanation was provided stating the reasons why the tract should be added in terms of changes that had taken place since 1960. No tract was added unless it was contiguous to a group of poor tracts and the resulting area had a combined population of 16,000 or more. Location of the 65 Health and Nutrition Examination Survey Stands by Region Region Stand Northeast .. New York Standard Consoli- dated Area (five stands) Philadelphia, Pa. (two stands) Boston, Mass. Pittsburgh, Pa. Albany-Schenectady-Troy, N.Y. Scranton, Pa. Springfield-Chicopee-Holyoke, Mass. Providence-Pawtucket, R.I.-Mass. Hartford-Tolland, Conn. Chemung-Tioga-Tompkins, N.Y. Mercer, Pa. Bedford-Fulton, Pa. Midwest Chicago Standard Consolidated Area (two stands) Detroit, Mich. Milwaukee, Wis. Minneapolis-St. Paul, Minn. Cleveland, Ohio Columbus, Ohio St. Joseph, Mo. Fargo-Moorhead, N.Dak.-Minn. 45 Region South . 46 Stand Region St. Louis, Mo.-I1l. Bay City, Mich. DeKalb-Steuben, Ind.; Branch, Mich. Cass-St. Joseph, Mich. Fayette-Ross, Ohio La Porte-Marshall-Starke, Ind. Boone-Greene, Iowa Fillmore, Minn.; Howard, Iowa New Orleans, La. Washington, D.C., Md., Va. Columbia, S.C. Knoxville, Tenn. Roanoke, Va. Savannah, Ga. Tampa-St. Petersburg, Fla. West Palm Beach, Fla. Natchitoches, La. Lamar-Marion, Miss. Cabarrus-Stanley-Union, N.C. Stand Clarborne-Hamblen-Hancock- Hawkins, Tenn. Barbour, Ala. Bullock-Jenkins, Ga. Sessex, Del.-Worcester, Md. Fayette, W. Va. .. Los Angeles, Calif. (two stands) San Francisco, Calif. Dallas, Tex. San Antonio, Tex. Tucson, Ariz. Omaha, Nebr.-Iowa San Diego, Calif. Fresno, Calif. Monterey, Calif. Clallam-San Juan, Wash. Grant, Wash. Gila, Ariz. Avoyelles, La. Ottertail, Minn. # U.S. GOVERNMENT PRINTING OFFICE : 1973 515-210/36 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 Originally 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: 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 basedon 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 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 tothe 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 ¢ischiirged patients in short-stay hospitals, based on a sample of patient records in a national sample cf 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 divovce.—Various statistics on natality, marriage, and divorce other than as included in regular annual or monthly reporis—special analyses by demographic variables, also geographic and time series analyses, studies of fertility, Data from the National Nalality and Movtality 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, HSMHA Rockville, Md, 20852 DHEW Publication No. (HSM) 73-1310 Series 1-No. 10 a U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service POSTAGE AND FEESPAID U.S. DEPARTMENT OF H.E.W. HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION HEW 396 5600 Fishers Lane Rockville, Md. 20852 THIRD CLASS BLK. RATE OFFICIAL BUSINESS Penalty for Private Use, $300 (Ne ab Z NCHS A 2 Cs yo % LAS PETE Ee RG Health and Nutrition Examination Survey TMC EER ETI BRE) U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration Vital and Health Statistics Series 1-No. 10b For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402 Ara orm A 3 TN ma rr Si mri an oa A IE ly 2 tim FYVEIEN Dire mld ran Series 1 PROGRAMS AND COLLECTION PROCEDURES Pre a) 1b Plan and Operation of the Health and Nutrition Examination Survey United States-1971-1973 A description of a national health and nutrition examination survey of a probability sample of the U.S. population 1-74 years of age: Part A-Development, plan, and operation. Part B-Data collection forms of the survey. DHEW Publication No. (HSM) 73-1310 U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE Public Health Service Health Services and Mental Health Administration National Center for Health Statistics Rockville, Md. February 1973 NATIONAL CENTER FOR HEALTH STATISTICS THEODORE D. WOOLSEY, Director EDWARD B. PERRIN, Ph.D., Deputy Director PHILIP S. LAWRENCE, Sc.D., Associate Director OSWALD K. SAGEN, Ph.D., Assistant Director for Health Statistics Development WALT R, SIMMONS, M.A., Assistant Director fot Research and Scientific Development JOHN J. HANLON, M.D.. Medical Advisor JAMES E. KELLY, D.D.S., Dental Advisor EDWARD E. MINTY, Executive Officer ALICE HAYWOOD, Information Officer DIVISION OF HEALTH EXAMINATION STATISTICS ARTHUR J. McDOWELL, Director GARRIE J. LOSEE, Deputy Director HENRY W. MILLER, Chief, Operations and Quality Control Branch JEAN ROBERTS, Chief, Medical Statistics Branch SIDNEY ABRAHAM, Chief, Nutritional Statistics Branch COOPERATION OF THE BUREAU OF THE CENSUS In accordance with specifications established by the National Health Sur- vey, the Bureau of the Census, under a contractual agreement, participated in the design and selection of the sample, and carried out the first stage of the field interviewing and certain parts of the statistical processing. Vital and Health Statistics-Series 1-No. 10b DHEW Publication No. (HSM) 73-1310 Library of Congress Catalog Card Number 72-600207 Appendix ITA. Appendix IIB. Appendix IIC. Appendix IID. Appendix IIE. Appendix IIF. Appendix IIG. Appendix ITH. Appendix I1J. Appendix IIK. Appendix IIL. Appendix IIM. Appendix IIN. Appendix IIO. Appendix IIP. Appendix IIQ. CONTENTS Part B HANES Household Questionnaire Food Programs Questionnaire . Medical History Questionnaire, Ages 1- 5. Medical History Questionnaire, Ages 6-11 Medical History Questionnaire, Ages 12-74 . General Medical History Supplement, Ages 25-74 . Dietary - 24-Hour Recall Questionnaire Dietary - Frequency Questionnaire . Health Care Needs Questionnaire General Well-Being Questionnaire Supplement A . Supplement B . Supplement C . Examination Forms (all examinees) Control Record ‘ General Medical Examination, Ages 1 74 Body Measurements . I Dermatology Examination . Ophthalmology Examination . Dental Examination Report of Dental Findings Report of Physical Findings Nutritional Biochemical Lab Data Form (all examinees) . Examination Forms (additional for detailed examinees) . Control Record ‘ General Medical Examination ‘ Goniometry . Respiratory Function Tests . Audiometry . TB Skin Test Report of Physical Findings APPENDIX IIA. HANES HOUSEHOLD QUESTIONNAIRE to others for anv purposes. 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 orreleased 0.M.B. NO. 68-R1184 APPROVAL EXPIRES DECEMBER 31, 1973] Form HESS (CYCLE IV) 1. Stand No. 2. Identification 3. PSU No. | 4. Segment No. 5. Serial No. [6. Questionnaire Mark one box 1 [] Housing unit 2 [] Other unit U.S. DEPARTMENT OF COMMERCE code BUREAU OF THE CENSUS ACTING AS COLLECTING AGENT FOR THE of U.S. PUBLIC HEALTH SERVICE HEALTH EXAMINATION SURVEY — questionnaires 7. Address or description of location (No. and St., City, State, ZIP code) | Listing |8. Year built — If “Ask” box is ““X’’d, complete | Sheet this item before the interview | | Sheet O a [J Do not ask | No. i City ! State y ZIP code | Line [C] Before 4-1-60 [J After 4-1-60 — Go to Q.12¢c, complete | | I No. ontinue interview if required and end interview 1 ! 9. Is —= your correct mailing address? [C1 Yes [J Ne . (What is your correct mailing address?) If this questionnaire is for an “EXTRA’’ unit in “‘B”’ or NTA Segment, enter: Serial number Item number Listing Sheet of original by whic (If in NTA Segment, also enter for Sample Unit found FIRST unit listed on property) Cy ry ZIP code Sheet No. Line No. | 1 L 1 — 10. Type of living quarters 11. Special place name i Type Type code | Ask: [Yes (fill Table X) J No [] Yes (fill Table X) [J No [1 Yes (fill Table X) [Ne [1 d. None (item L) [J a. Are there any occupied or vacant living quarters besides your own in this building? [] b. Are there any occupied or vacant living quarters besides your own on this floor? [1 c. Is there any other building on this property for people to live in — either occupied or vacant? [] None 15. What is the telephone number here? 16. INTERVIEWER (Ask only for households with EP’s) The information you have just given me will be used by the Public Health Service to determine which persons will be asked to participate in the other part of this survey. That part will cover health and nutrition. If anyone in your household is tive of the U.S. Public , a (Complete items 1-14, 17-20) [CJ Refusal — Describe in footnotes [No one at home — repeated calls Goto [0] Vacant — seasonal 19a [C] Temporarily absent Other — Specify. 0 by [] Armed Forces [C] Other — Specify (Complete items 1-12, L, 14, 17, 18, and 20) [T] Vacant — non-seasonal [_] Usual residence elsewhere a ITEML | 2] Rural (13) 1 [J All other (Q. 1, p. 2) Health Service will be calling on you within a i week or so to explain the second part. What 13. Do you own or rent this place? []10wn [Rent ["] Rent free hii og rg fererisvisiiyoy =~ 4a. How many acres of land are included? 1 [110 or more 2 [] Less than Day Time acres (b) 10 acres (c) a.m, pom. b. During the past 12 months did sales of crops, livestock, and 2[]Yes(Q. 1, 4a[JNo(Q. 1, other farm products from the place amount to $50 or more? p-2) p- 2) Namesof respondent c. During the past 12 months did sales of crops, livestock, and 3[ | Yes (Q. I, sINo(Q. 1, other farm products from the place amount to $250 or more? p- 2) p- 2) LEAVE THANK YOU LETTER 17. RECORD OF CALLS AT HOUSEHOLD 1 Com. 2 Com. 3 Com. 4 Com. 5 Com. 6 Com. Date ne pom. pom, pom, pa pom: pom, 18. REASON FOR NONINTERVIEW TYPE A TYPE B TYPE C TYPE Z (Complete items 1-8, 11, 17, 18, and 20) [] Demolished [] In sample by mistake [] Eliminated in sub-sample [] Built after April 1, 1960 [_] Other Specity — (Partial interview) Interview not obtained for: Person No. because: 19a. For “final’” Type A noninterviews enter names, approximate ages, and sex of household members. 19b. Who supplied this information? Name Age | Sex Name Age [Sex Name L 4 Number and street, route, or box number 2. 5, City 3. 6. 19c. Race 20. Signature of interviewer "| Code ow CIN CJ or ! Footnotes WASHINGTON USE ONLY Total number Total number o of persons sample persons * — a. What is the name of the head of this household? — Enter name in first column. Yes* No 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? i d. Have | missed anyone who USUALLY lives here but is now away from home? .................... Oa e. Do any of the people in this household have a home anywhere else? .......................... | i A i | If any adult males listed, ask: * Apply household membership rules. f. Are any of the persons in this household now on full-time active duty with the Armed Forces of the United States? ....... [] Yes—» Col(s). (Delete) [No 1 0 First name © Last name Relationship 2. How is —— related to —— (Head of household)? 2. HEAD AGE (RACE SEX 3a. How old was —- on his last birthday? — Enter Age and circle Race and Sex. 3a. iwansotlim2F | Month [Day [Year b. What is the month, day, and year of —=s birth? — Use card to check birth date and age for consistency. b. | INTERVIEWER: Mark the box for each person age 1-74 years and CONTINUE. DO NOT CONTINUE for persons under 1 or 75 years of age or over. If no EP, go to page 1, question 15. C [11-74 years (EP) State or foreign country 4. In what State was —— born? Enter the name of the State or foreign country. 4. Ask for all EP’s 17 years old or over: 1[] Under 17 4 [_] Nev. married 2[] Married 5] Divorced 5. Is —— now married, widowed, divorced, separated, or never married? — Mark one box for each EP. 5. [3[_] Widowed 6 [_] Separated Ask for all 10 [_] None (NP) EP’s 6 years 2Flem...... 12345678 old or over. d. What is the name and location of the school —— goes to? d.| Name and location Ask for . children 7a. Has —— ever attended a school of any kind? 7a.| 17] Yes 2[]No (NP) 3 Jems 1 [Nursery 2 [] Kinder : 3] Other gRnen b. What kind of school? b. Specify Ask for all EP 8a. Is any language other than English frequently households. Spokonhoa NUS OOM oe ACI YORE e[INe (9) EE b. What language(s)? Language(s) spoken If “Negro” 9. | Ancestry or national origin (Nin Q.3) 9. Which of the groups on this card — (hand card) best describes your [] Negro do not ask — (your husband's; or —="s) MAIN ancestry or national origin? Mark Negro box. (Additional probe: What is your MAIN ancestry or national origin?) Ask for all 10a. What was —— doing MOST of the past THREE months — 10a. [1 [] Working 2 [] Keeping EP’s 17 years (for males): working or doing something else? (100) house (10c) sir ove: mmm mm mmm mmm 08 females): kosping house, working, or doing something else? | ls[lSomewingelserony b. What was —— doing? b.|1[] Retired 2[_] Student 3 [_] Other — Specify Did == work at a job or business AT ANY TIME during the past THREE months? | «|1[JYes _ 2[INocasy d. When —— was working, did he work full time or part time? d.|1 [J] Full time 2 [_] Part time 11a. Did —— work at any time last week or the week before? (for females): not counting a. [1] Yes (12) work around the house? 2[]No (11b and c) b. Even though ~~ did not work during that fime, does he have gjobor business? === { be | CI Yee fre) 2% | c. Was he looking for work or on layoff fromajeb? | od 1 dd Lod 1 [J] Looking 3 [_] Both. d. Which — looking for work or on layoff from a job? d. |2 [] Layoff : Employer tiie Fr gen If “Yes” in 11c only, questions 12a Ask for all EP’s with a “Yes” in lla, b, or c. through 12¢ apply to this EP’s LAST 12a. Who does (did) =~ work for? full-time civilian job. 2a. Ks i es tii fl a fia ~ |Business or industry | b. What kind of business or industry is this? b. a a TT TE 32 tT 7 c. What kind of work is (was) —— doing? ec d. Class of worker d. [1 [[] Private paid (VP) Fill 12d from entries in 12a—12c, if not clear ask. 2 [] Gov. Federal (NP) 3[_] Gov. other (NP) 4 Own (12e) 5 Nonpaid (NP) 6 [_] Never worked (NP) . |1 [] Yes WP) 2] No (NP) 13, How many rooms are there in this house (these living quarters)? Count the kitchen but not the bathroom. i 2°84" 8 Circle number of rooms ——— 6 7 8 9ormore 14a. Is there piped water in this house (these living quarters)? 1] Yes 2] No(15a(2)) b. Is there both hot and cold piped water? 1] Yes 2[]No 15a. Does this house (these living quarters) have the following kitchen facilities — WAsinkwithpipod wate? (10JYes __ 2[]% (2) A range or cook stove? 1] Yes 2[]No DARD cin Les. 20000 If “Yes” to all three above, ask: . b. Are these kitchen facilities used by anyone NOT living in this household? 1] Yes 2[]No 16. Please look at this card — Group Which of these i income groups represents yours, your —= 's etc., total combined family income for the past n[JAan s[JEan wl (pe. 0. 12 months, that is, date) a year ago? Include income from all sources such as wages, salaries, 12 B17) w[_JF(m = Jie-D social security or retirement benefits, help from relatives, rent from property and so forth. i]can wv Jean 21 JK. 0 : 1a JD7) 8 JH pe.» 22 JL(p.1) If A—G is marked in question 16, ask: 1] Yes — How much altogether diols 17. During the past 12 months, did you or any members of your efore deductions? family receive any money from wages or salaries? 2[JNo $ 18. During the past 12 months, did you or any members of your family receive any money from — Aston: a. Social Security or Railroad Retirement? 1 [] Yes — How much altogether? 2] No $ b. Welfare payments or other public assistance Amount (such as aid to families with dependent chil- _ ? dren, old age assistance, or aid to the blind or 1 [0 Yes — How much altogether totally disabled)? 2] No $ rp a 5 a wt FS wR Rs BR SE==EmECEERS 1 [] Yes — How much altogeth, nt c. Unemployment compensation or workmen's compensation? 2[] No $ d. e. - ? f. Net income from their own nonfarm business, 1 [J Yes — How much altogether professional practice, or partnership? 2] No $ g. Net income from a farm? (Net after operating Not incons expenses. Include earnings as a tenant farmer [] Yes — How much altogether? or sharecropper. If farm lost money, write $ “Loss” above amount.) 2[JNe ee h. Veterans payments? 1 [] Yes — How much altogether? Ea 2[JNo $ 1 Yeo — How mock shoasthar? TA Amount TTT i. Alimony, child support, or contributions from 1 [J Yes — How much altogether persons not living in this household? 2] No $ i 1 [] Yes — How much altogether? a 2[JNo 3 Total amount INTERVIEWER: Enter the sum of all money received from all sources in questions 17 and 18, and continue interview with question 15 on the household page. $ TABLE X — LIVING QUARTERS DETERMINATIONS AT LISTED ADDRESS LOCATION * OF UNIT B SEGMENTS ONLY USE OR CHARACTERISTICS CLASSIFICATION | IF HU IN B SEGMENT ASK: Where are these If listed, enter | INTERVIEWER: Are |Are these OCCUPIED ALL QUARTERS N — Not a separate |In what year (If before July quarters located? sheet and line [these quarters within|(specify unit, add occupants |were these 1960) | number and [the specific sample |iocation) | P° the Do these quarters in 110 this question- | quarters [peer esaq) Spoil. stop. address shown in quarters for isp a (specify location) have: |naire, (specify hs Yate , ese (specify e.g., basement; 2nd | If unlisted and: Salinas 24 of the mors then | [37%28 (Complete a focation) household egment List? one group of 1 ¢ tion- | created? floor, rear) — B Segment — quarters live [Direct access|A kitchen or separate question head of these Line Go fo Col. 4 \0t "Wes, continue (PO2012 d h naire for each (If 1959 or varters on No. | at outside Area . s,”’ continu and eat wit from the |cooking fated q 2 A Table X. If “No,”” |(If “Yes,” any other ide or unre ater person 1960, specify | April 1, 1960? Segment boundary, | ~ Atea STOP Table X and fill one line [group of through for exclusive | Zt Grovp) «rn it prt specify in notes; Segment — . tis rough a or exclusive 1f, pn STOP Table X and Go to Col. 5 | continue with item for each people? common hall? |use? half, or ; z 120RL) group) if last half.) continue with item HU Separate FORE) Ot | unit Interview on a separate question- w @ ® @ ©) © @ ® [© (10) an 1 S— L—| Y N Y N Y (9) N Y N N HU Ot 2 Se Yet JY N Y N Y@ Ni Y¥Y N N HU Ot 3 $s bei] - N Y N Y@® N|Y N Y N N HU Ot NOTE: Continue interview with next item of the Household Page. APPENDIX [IB. FOOD PROGRAMS QUESTIONNAIRE HSM-411-11 (PAGE 1) Form Approved REV. 5/71 O.M.B. No. 68-R1|184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY HEALTH SERVICES AND MENTAL HEAL TH ADMINISTRATION A Tpjossiion which wiogle peng NATIONAL CENTER FOR HEALTH STATISTICS identification of the individual will be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, HEALTH AND NUTRITION EXAMINATION SURVEY FOOD PROGRAMS QUESTIONNAIRE and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Name of respondent (Last, first, middle) b. Deck No.| c. Segment No. d.Serial No.|e. Column No. WY oo des Tn FOR INTERVIEWER USE ONLY , Not applicable } 1 Items | and 2 not applicable by HES income Mark appropriate box before going into household. : tl and family size i 20pi — RS to 3a | ! Applicable 2[] No program available — SKIP to 3a 3[] Food stamps available — Ask la 4] Commodities available — SKIP to 2a i | | | I la. Are you certified to participate in the 1% 177] Yes — Ask b | 1 1 \ [ food stamp program? IN Sas } skip to 30 9 [ Don't know i ? Yl - b. Are you buying food stamps now? b 1 0 Yes, regularly a 2[ 1 Yes, occasionally ; 3[ 1 No-Askc i i 2 I IN rs oy ons “Gn iT3N nes ! 2[ | Not enough money at the time 3] No transportation 4[] Pride s [| Other — Specify 2a. Are you certified to participate in the 2a. J 1] Yes — Ask b commodity distribution program? | 2] No | ot , SKIP to 3a ! 9] Don't know | f b. Are you receiving commodity foods now b. | 17] Yes, regularly Pd for your family? 2] Yes, occasionally Sips 3] No — Ask c c. Why aren't you participating in 6 the program? 1] No need 2 [| No transportation 3[_] Pride a [| Other — Specify. Ask the following questions First name i Deck No. [Sample No. only in households where there are sample children or BEGIN NEW RECORD 102 youths attending school. pel i t 3a. Is there a school lunch program at the 3a. ! 1] Yes — Ask b school that . . . attends? ! 2] No | 2 {swap to d ! 9 [] Don’t know b. How many times a week does he b. | usually participate? | __ Times c. How much does he pay for his lunch ec! per day? : a wa CONES i d. Is there a special milk program at the d. | 17] Yes — Ask e school that . . . attends? ! 2 No t ski to f i 9 [] Don’t know e. How many times a week does he usually e. participate? Times f. Is there a school breakfast program at the 2 + [1 You Ask 2 ond zs VGo to next sample child 9 [1 Don’t know | 1 ! i i school that . . . attends? ! i | | \ | | | | | g. How many times a week does he usually g. 5 participate? __Times h. How much does he pay for his breakfast per day? _ __ Cents oy —t ~Nr The same questions are asked for any further sample children or youths attending school. APPENDIX 1IC. MEDICAL HISTORY QUESTIONNAIRE, AGES 1-5 HSM-411-8 (mace 11 Form Approved REV. 5/71 0.M.B. No. 68-R1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE rE ora nnn EE EE esprit AIL information which weuld permis HEAT TIONAL CENTER FOR HEAL TW STATISTICS identification of the individual will HEALTH AND NUTRITION EXAMINATION SURVEY bs phy austin, Slse and for the purposes of the survey, MEDICAL HISTORY QUESTIONNAIRE — AGES 1-5 and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Child's name (Last, first, middle) b. Deck No. |[c. Sample No. d. Segment No. oer {| be am e. Serial No, |F. Column No. |g. Sex i. Age 7. Date of birth 1[1Male Month Day Year a 2] Female 0 a Le ria 1. How much did . . . weigh when he was born? Li | | _ _ Pounds _ _ Ounces | 9999 [~] Don't know 2. Was... born prematurely? (that is, early or 21 10] Yes not carried the full nine months) \ 2] No i O ! 9 [_] Don’t know T | 3. How old was . ..'s mother when . . . wos born? 3. | _ __Years old | 95 [] Don’t know 7 4a. How many children has . . . 's mother had? 4a. Children — If more than I, Ask b | a9 [7] Don’t know — SKIP to 5 : y b. How many were born before . . . ? be! _ _ Children ! 99 [] Don’t know ! 5. How many of . . . 's brothers and sisters weighed 5. | __ Brothers and sisters less than five and one half pounds of birth? i 59 [] Don't know : 6. How much did . . . weigh when he was o 6 | _ __Pounds year old? i 99 [7] Don’t know ; T 7. How much did . . . weigh when he was two 7.0 0) _ _ Pounds years old? } 88 [] Not yet two | 99 [_] Don't know + T 8. How old was . . . when he got his first tooth? 8. | _ Months } 99 [_] Don’t know ’ | 9. How old was . . . when he first sat up i __ _ Months by himself? } 88 [| Doesn't sit up yet : 99 [_] Don't know Tr 10. How old was . . . when he first walked 10. | _ _ Months by himself? | 88 [] Doesn't walk yet | | 99 [7] Don’t know } Vie. Was... . broust fod at ony time? Na. 1] Yes — Ask b | ! 21h SKIP to 12a 3 | 9 [] Don't know I b. How old was he when he stopped ! _ _ Months breast feeding? § 88 [] Still breast fed ! 99 [] Don’t know : 120. Asn baby, wos . + «9% any tine fod 12a. 1 [Yes — Ask b milk from a bottle? 1 2[INo i SKIP to 13 P 9 [[] Don't know b. What type of milk was used? b. | | Yes No Don’t know | (1) Whole cow's milk «o.oo... om] 10 2] sO (2) Commercially prepared milk = : Specify brand if known 2! | ii sO | (3) A soy base formula «vu uuuu. 3)! Al 20 9s] (4) Other — Specify 4) Cl 2] 8 [J 13. How old was... when he first started eating 13. | solid foods like cereal or fruit? : _ Months INTERVIEWER ~ Convert replies in weeks | Bn to nearest whole number of months. ! $2 LY 0on't: know 14. Has . . . had the following immunizations? 14. | Yes No Don't know DPT (Diphtheria, whooping cough, and tetanus) . .! 10 20] (1 | Polio sis aims wr we REISS ST SATE SA 4) a 20] s (J ® o FL RR PRP (17) J 2] sO Measles. ..... AT aan v eens @ 30 2] s[J Garman Measles. 's + » «vv ssivivivmu vais im] a0] 5s] Mumps . EE ARs eng oI i s[] Other, don’t know what for. «+. vvvve.s 10 2] s [J 15. Does or did . . . have any conditions he was born with that involved any of the following? ! Yes Don't know | Heart. ovvvvuunnnnneninninnenenssssl @) HL 9] BYR sisi RR RE 10 s[] Mouth or throat . . . . + s [1] Stomach or intestines . . . . 0 es] Kidneys or urinary system . 1 s[] Muscles, bones, or joints . 10 Ey 3] Brain or nervous system . . $d 2] [7] a . What are they? T 160. Has . accidentally swallowed 16a. | 1[7] Yes — Ask b any medicine, pills or poison? | 2 No l SKIP to 17 | 9 [] Don't know ¢ | b. Did this result in any serious damage? | 1[7) Yes — Ask ¢ ! 2] No — SKIP to I7a c. What was it? inseam T 17a. Hos . . . ever had a bad accident? 17a. | 17) Yes — Ask b : 2[ No SKIP to 18a ! 9 |] Don't know b. Does he still have the effects of it? b. | 10] Yes — Ask ¢ 2[_| No — SKIP to I8a by this questionnai 180. Has . . . ever stayed overnight in 18a. | 1] Yes — Ask b hospital? = Serpe : 2[Z)No — SKIP to 19 b. For what? ! i c. Has... ever had an operation? «! 17] Yes — Ask d 1 = & Forel? i 27] No — SKIP to 19 I | + 19. Does... have any allergies? 9. | 10] Yes : 2[JNo | 9 [_] Don’t know ; : + 206. How many times has . . + had 200. | __ Times pneumonia? : i b. Does he have it now? bn! 107] Yes | 2[]No 21a. During the past six months how many 21a. | colds has . . . had? __Colds r b. Does he have one now? b! v[ Yes ! 2 [No T 22a. During the past six months has . . . a! 1 [0] Yes — Ask b passed any worms? | 2CINo ! ioe SKIP to 23a ! 5 [C] Don't know b. What type, tiny white or pencil-sized ? b. | 1 [7] Tiny white | 2] Pencil-sized | 3 [J Both L 23a. During the past six months how many 23a. | ; times has +» - had diarrhea? 1 @) — Times b. Does he have it now? bl VC] Yes i 2(T]No 24a. Does . .. ever eat dirt or clay, starch, 24a.) paint or plaster, or any material that might ! 1 Yes - Ask b be considered unusual? ! 2] No = SKIP to 25 f b. Which? bei Yes No ' | (1) Ditorclay «oovuuunns wenvianvse AM 10 2] | (2) Bik: ees sasnanmpnerrenneey: AB GY 5D 20] | | (3) Paintorplaster «ouvususerernannn @! TO 20] | (4) Other - Specify cere. HY ad 2] | T 25. Does... have unusual trouble seeing 5. |! 1] Yes at night or in the dark? ! 2[INo | 9 [_] Don’t know Here are some questions about . . . 's mother: : 2%a. How much does she weigh? 2%a. | — — — Pounds ! 999 [_] Don't know ! i b. How tall is she? b.! | | _ Feet — Inches ! d 999 [] Don't know Here are some questions about . . . 's father: | 27a. How much does he weigh? 27a. @)— — _ Pounds | 999 [_] Don’t know b. How tall is he? i : — — Feet _ __ Inches | 999 [] Don't know Za. Do you vse iodized table seit? 280. | Efe) epee | 2] No 4 9 [_] Don’t know — Ask b b. May I see your box of table salt? b.! 1 [1] lodized i 27] Not iodized ; 3 [CJ No box 29a. Name of respondent i ; | b. Respondent's relationship to child covered b + [7] Mother | | 2[] Other ~—— APPENDIX IID. MEDICAL HISTORY QUESTIONNAIRE, AGES 6-11 HSM 411-9 (pace 1 REV. 5/71 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION ATIONAL CENTER FOR HEALTH STATISTICS HEALTH AND NUTRITION EXAMINATION SURVEY MEDICAL HISTORY QUESTIONNAIRE — AGES 6-11. Form Approved 0.M.B. No. 68-R1184 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. d. Segment No. 7 ee oe e. Serial No. [f. Column No. |g. Sex h. Age i. Date of birth 1 [Male Month Day Year I HET 2[_] Female i ies — _ I 1. How much did . . . weigh when he was bom? 1. | | — — Pounds — — Ounces | : 9999] Don’t know 2. Was... born prematurely? (That is, early 2. 1] Yes or not carried the full nine months) 2] No s [] Don’t know | I 1 i | I 1 i 7 , ? | 3a. How many children has . . .'s mother had? 3a. | wo Cl rant moraithon 1, Ad i 99 [_] Don’t know — SKIP to 4 | 1 . i i b. How many were born before . . .? b. | = ~< Children | 99] Don’t know 4. How La of 3 2 pretbing sad USE OF TOBACCO ! 1] Yes — Ask b 7a. Have you smoked at least 100 cigarettes Ta. | 2] No — SKIP to 8a during your entire life? I —- ® b. Do you smoke cigarettes now? b. i 1] Yes — Ask c | No — SKIP to d c. On the average, about how many a day cl @d cigarettes per day do you smoke? | (Enter answer and SKIP to ) d. How long has it been since you smoked d! 77 [7] Under one year — Ask e sige toinly ralaniy? years — Enter number of years and ! i = ! SKIP to f 88 | Never smoked cigarettes regularly — SKIP to 8a 39 [7] Don't know — Ask e e. On the average, about how many el bebo Rondon TE — — cigarettes per day 12 months ago? 88 |_| Did not smoke 99 [| Don't know f. During the period when you were f. smoking the most, about how many — — cigarettes per day cigarettes a day did you usually 99 [| Don't know smoke? g. About how old were you when you g _ _ years old | f Fuses res i | 08 [7] Never smoked regularly ? | i | ! | 99 [] Don't know 8a. Have you smoked ot least 50 cigars during your entire life? b. Do you smoke cigars now? c. About how many cigars a day do you smoke? d. About how long has it been since you smoked 3 or more cigars a week? e. About how long has it been since you smoked 3 or more cigars a week? f. Twelve months ago, about how many cigars a day did you usually smoke? 2] No — SKIP to 9a Yes — Ask ¢ No —- SKIP toe _ cigars per day — SKIP to f § (IF LESS THAN 1 PER DAY) 88 [13106 per week — SKIP to 59] Less than 3 per week — Ask d 77 77] Under | year — SKIP to f __ __years — Enter number of years and SKIP to 9a 88 [] Never smoked 3 or more cigars a week — SKIP to 9a 99 [] Don't know — SKIP to f 77 [7] Under | year — Ask f — — years — Enter number of years and SKIP to 9a 88 ~] Never smoked 3 or more cigars a week — SKIP to 9a s9 [7] Don't know — Ask f _ cigars per day 3 (IF LESS THAN 1 PER DAY) 1113106 per week Less than 3 per week 37] Did not smoke cigars 9a. Have you smoked at least 3 packages of pipe tobacco during your entire life? b. Do you smoke a pipe now? c. About how many pipefuls of tobacco a day do you usually smoke? d. About how long has it been since you smoked 3 or more pipefuls a week? e. About how long has it been since Iv smoked 3 or more pipefuls a week? f. Twelve months ago, about how many pipefuls a day did you smoke? 7] Yes — Ask b 2[]No = SKIP to Ifa 1] Yes — Ask c 2[JNo-SKIP toe — .— pipefuls per day — SKIP to f on page 4 § (IF LESS THAN 1 PER DAY) 113 to6 per week — SKIP to f on page 4 27] Less than 3 per week — Ask d 77 [_] Under | year — SKIP to f on page 4 — years — Enter number of years and SKIP to 10a 88 [T] Never smoked 3 or more pipefuls a week — SKIP to 10a 53 [1 Don't know — SKIP to f on page 4 77 [J Under | year — Ask f on page 4 — -— years — Enter number of years and SKIP to 10a 88 [| Never smoked 3 or more pipefuls a week — SKIP to 10a 99 [] Don't know — Ask f on page 4 — — pipefuls per day § (IF LESS THAN 1 PER DAY) 1013 to 6 per week 2[] Less than 3 per week 3 [_] Did not smoke a pipe 10a. Do you presently use any other form of 1] Yes — Ask b tobacco, such as snuff or chewing tobacco? 2 No — SKIP to Ila b. What? b. Yes No Snuff LL... RRS Re ee 0 2] Chewing tobacco ....... a 8 0 2) Other (Speci | ] [ er (Specify) | 0 2] DP HEARING ! 11a. At any time over the past few years, have Na. t 10] Yes — Ask b you ever noticed ringing in your ears, or : have you been bothered by other funny i 2[INo — SKIP to I20 noises in your ears? ! b. How often? bei 1 [J] Every few days \ 2[T] Less often c. Does it bother you? ey + [CJ Quite a bit : 2[] Justa little ! 3[JNotatall 12a. Have you ever had a running ear or any 12. | 10] Yes — Ask b discharge from your ears (not counting ! 2 No wax in the cars)? i Ate SKIP to 13a | s [7] Don't know b. How often have you had this? b. | 1] Once only ~~ 3[] Three or more times i 2 [] Twice 9 [| Don't know 136. Have you ever had deafness or trouble hearing with one or both ears? b. Did you ever see a doctor © about it? c. How old were you when you first began having trouble hearing? d. Since this trouble began, has it gotten worse, gotten better, or stayed about the same? 1] Yes — Ask b 2] No — SKIP to 14 Yes No 2] | 1] 0-4 years old [7] 30-39 years old 2[C]5-9yearsold 6 [] 40-49 years old 37] 10-19 years old 7 [7] 50 years old or older 4 [7] 20-29 years old 1] Gotten worse 3 [| Stayed about the same 2 [_] Gotten better 13e. What was the cause of your hearing 13e. | trouble or deafness? | Enriinfeetion..., i vuoi waincniwisis i (08) 1] 2] Bomwithit |... .............. : J 2] i Loud noise (such as that from | machinery, gun fire, blasts or | SARIORONEY proie vooremmraron wists i ves i 0 20) Eor surgery . «eevee i 0 20 2 i 10 2] Other (Specify) rei a 20] Don't know ..vvvveii i sO) f. How would you rate your hearing £| 1] Good ? in your RIGHT ear? 2[C]A little decreased 3] A lot decreased 4 [7] Deaf READ - The following series of questions will be about | i i i : g. How would you rate your hearing 9. | 1 [] Good in your LEFT ear? | 2[T] A little decreased | 3 [] A lot decreased i 4 [] Deaf h. Have you ever attended a school hi or class for those with poor 1 CYes hearing or a school for the deaf? | 2[JNo i. Have you ever hod any training io | VC] Yes in lip reading? ! 20INo 1. Have you ever had any training 5 A Ap J | @ re because of poor hearing? ! 2] No r k. Have you ever had any training k.! 1 Yes in how to use your hearing? | 2] No | ; I. Have you ever had an operation Lt 10] Yes on your ears? | ! 2[JNo m. ave you ever had your hearing m | 1] Yes ested? | 2] No — SKIP to p on page 6 n. How old were you when ni 12] 0-9 years old your hearing was first | 10-19 1d tested? : af 10-19.ysnisis i 3] 20-29 years old | 47] 30 years old or older o. How often do you now have ol 1] Twice a year your hearing tested? y 2 2 Once a i | ! 3] Once every two years ! a[_] Less often than once every two years p. Have you ever used a hearing aid? pe | 10] Yes i 2] No — SKIP TO 14 q. Which ear? 5 1] Right | 2] Left | 3 [7] Both r. With a hearing aid, is your no 1] Yes hearing better? ! - N ! 2] No T | had in the past, or might even have at the present t' ne. specific medical problems or conditions you might hav» Please answer “Yes or “No’’ to each question. 14. Have you ever had -- 14, a. Pain or aching in any of your joints a either at rest or when moving them, this condition being present for AT LEAST ONE MONTH? 10] Yes 2[JNo b. Pain in your neck or back, tis poin b. aving been present for AT LEAST Y N ONE MONTH? 10 Yes 200s c. Pain in or around either hip joint o (including the buttock, groin, and side of the upper thigh) or knee (including the the back of the knee), this pain having been present for AT LEAST ONE MONTH? 1] Yes 2[TINo g of a joint, with pain present d. oint when touched, this condition present for AT LEAST ONE MONTH? 10] Yes 2] No . Stiffness in the joints and muscles e. when getting out of bed in the morning, the stiffness lasting for AT LEAST 15 MINUTES? 1] Yes 2] No . Trouble with recurring persistent £ cough attacks? 1] Yes 2[JNo . A cough first thing in the morning in the 9. winter? (Count a cough with first smoking or on first going out of doors; exclude clearing of throat or a single cough.) 1] Yes 2] No . A cough first thing in the morning in h. the summer? 1] Yes 2[No Any phlegm from your chest first thing be in the morning in the winter? (Count phlegm with the first smoke or on going out of doors; excluding phlegm from the nose. (Count swallowed phlegm.) Any phlegm from your chest the first i thing in the morning in the summer? 10] Yes 2[JNo 10] Yes 2] No 1[C]Yes — How 2] No— SKIP to I4L many times? 1 [CJ One time 2[] Two times 3] More than two times = . During the past three years, a period k. of increased cough and phlegm lasting for three weeks or more? ®e0® 14L. Trouble with shortness of breath, when 14L. | hurrying on the level or walking up a ! 1] Yes 2[] No slight hill? : m. Wasszy or whistling sounds in your m. | 1] Yes 27] No ® L n. Trouble with any pain or discomfort no Sa T®@ ove om o. Trouble with any pressure or heaviness 0 sensation in your chest? ! 1] Yes 2[]No r p. Severe pain across the front of your [3 chest lasting for half an hour or 4 1] Yes 2] No more? | q. Pains in either leg when walking? q. 1] Yes 20] No r. Heart failure, or ‘‘weak heart’, of Tu any degree of severity? i 1 Yes 2[JNo i s. Infections of the kidneys or bladder? s. | 10] Yes 2] No : Fgh t. Blood in your urine? t. | Yes 20] No u. Pain or burning sensation when passing wi urine? i TC ¥es 2LaNe v. Loss of vision or blindness lasting “ ; You 2] No from several minutes to several days? ! - i w. Difficulty in speaking or very, slurred w. | speech lasting from several minutes to | @ 1 Yes 2] No several days? 1 x. Prolonged weakness or paralysis of one x0! . or both sides of the body lasting up 1 @) [Yes 2] No to several months? ' y. Loss of sensation or numbness or y. i tingling sensations lasting several g @ 1] Yes 2] No minutes to several days? | z. A severe head injury leading to z. | unconsciousness lasting for more than 1 five minutes? ! @ Ove 2LINe DIABETES | @) 1 Yes - Ask b 15a. Do you have any reason to think that you 15a. | 2 [7] No — SKIP to léa To have diketar, sometimes called sugar | iabetes or sugar disease? | Yes — A b. Did a doctor tell you that you had it? b. = Ya is g ae i © How long ago did you start c. | @D 17] Less than one year ago having it? | 2[] |-4 years ago } 3[C] 5 or more years ago r ! 1[J Yes d. Do you take insulin? d. ! 2[JNo r e. Do you take any medicine by e | 1] Yes — Ask f mouth for diabetes? : 2 [J] No = SKIP to léa f. What is the name | of the med ? ! GOITER/THYROID | Yes — Ask b 16a. Have you ever had a goiter or any other 160. | tL Yes 17 thyroid trouble? ] 2[JNo—SKIP to I7a | i o b. Who told you that you had b. i @) 1 [] A doctor 3] Other goiter or thyroid trouble? ! ] 2[] A nurse c. ls, or was, your thyroid; e 1 [[] Overactive 3] Neither Overactive (hyperactive) : @ , , Underactive (hypoactive) i 2 [] Underactive 9 a Don't know r d. How long ago did you first have d @ 1 [J Less than one year ago 3[] 5-9 years ago this trouble? A hie oe mee ee | 2[] 1-4 year ago a] 10 or more years ago ! el ee ta me i e. Have you been treated by a doctor e. | = for goiter or for thyroid trouble? ) @ 1 Yes Asks | 2] No — SKIP to 17a | f. How? fl Yes No | Medicines: uv oivsms mais vans vuvene @) 3 2] 1 BUOY vrei 4 En TT RRA Lo 1@® oO Tm] | ROBIN (4/3 wuinar® pbcwinie vse dw wa wie FV @ vO 2] i i Other — Specify — ' | 0 20] | T g. Are you currently being treated 9. ! i y 1a Yey ! 2[]No h. Are you currently taking any pills he } 1] Yes or medicine fo help you lose or ! gain weight? ! 2] No 1 18 i. When was the last time you saw a doctor about goiter or thyroid trouble? 1] Less than one month ago 2[] 1-3 months ago [_] 4-6 months ago 4[_] 7-11 months ago s[] | or more years ago 9 [| Don’t know b. Do you have a plate for your upper jaw? c. How long have you had your plate? d. Have you ever had a dental plate for your upper jaw? e. How long has it been since you had any teeth to chew with (natural or false) in your upper jaw? 6 [| Never SKIN CONDITIONS ; 17a. Have you ever had any of the following 17a. skin conditions? Yes No Acne or pimples . «vu venetateuanns @® iO 2] PSONOSHS « «eve enenenen eens ®» 2] Moles or birthmarks. +. oo ovovenunns OJ 2] Unusual loss of hair... ..oouou.on.. LB 2] Bomemus:s 3 45s Tvies BERR 3 SR : 1 2] | ! py WEIS cnc coievas. Homie Bs s int LE) 20] Hives ..o ux vo wins non vinn inane 56 fae l + 2 | b. If ““Yes’’ — Were you treated by a doctor for it? b. i Yes No A EARN scoiwsinic 3 Ad Bd SED | 1 cne or pimples ! 1] 2] | Proriasie 53s 4 vk aon semen ve mis fC] 2] Moles or birthmarks... ...vvuvuvnns | 10 2] | . ’ | , oz Unusual loss of hair +. 'voueun.n.. | 10 2 ECZEMa «ov vvvernnnennnnnennnns | 0 20] i Waite 3ivis-irsis soem O R ds e i 10 2) i | HIVOE + + svaminin opinion rosin waiwiviss 1 2) | | Pp TEETH | i Yes — Ask b 180. Have you lost oil your teeth from: youe 180. | 1 Yaeee upper jaw? | 2[7] No = SKIP to 19a = 1] Yes — Ask ¢ 2[]No—SKIP tod ® 1[] Less than | year 2] 1-4 years 3[] 5-9 years SKIP to 19a a[] 10-19 years 5] 20 or more years 1] Yes 2[ No 1] Less than | year 2[] 1-4 years 3[]5-9 years 4[ 110-19 years 5 [_] 20 or more years 19a. Have you lost all your teeth from your lower jaw? o- . Do you have a plate for your lower jaw? c. How long have you had your plate? d. Have you ever had a dental plate for your lower jaw? e. How long has it been since you had any teeth to chew with in your lower jaw? 19a. | (5) 1] Yes — Ask b 2[] No — SKIP to 20 1[]Yes — Ask ¢ 27] No — SKIP to d [7] Less than | year 2[] 1-4 years 3[7] 5-9 years SKIP to 20 [110-19 years 5] 20 or more years > 1] Yes 2[JNo 1] Less than | year 2] I-4 years 3[]5-9 years 4[] 10-19 years 5 [120 or more years © If the respondent doesn’t have any full plates, (“*No”’ to questions |8b and 19b) SKIP to the instructions above question 24. 20. Do you usually wear your plate(s) while 2. eating? | 21. Do you usually wear your plate(s) when 21, (®) 17) Yes not eating? ' 2FUNe 22. Do you usually use denture powder or cream 2! 1] Yes i ? to help keep your plate(s) in place? i C1 No | 23. Do you think you need a new plate or that 2. 1 No the one(s) you have need(s) refitting? 2[7] Yes, one 3] Yes, both 9 [_] Don’t know ® If respondent has no natural teeth, (**Yes'' to ques- tions 18a and 19a) questionnaire COMPLETED. © [f the respondent has any natural teeth, CONTINUE. 24. How would you describe the condition of your 24, 1 7] Excellent TEETH? v = i ; 3[] Fair | 4[_] Poor T 25. How would you describe the condition of 25, | 1 [7] Excellent your GUMS? i = 2 [_] Good I 3[] Fair ! 4] Poor . | 26. Do you think that your teeth need cleaning 26. now by o dentist or dental hygienist? 1] Yes \ 2] No ! 9 [] Don't know 27. How many times o day do you usually brush ~~ 27. | teeth? Yoseites : — Times 28. Do you think that you ought to ge te a 8. | dentist now or very soon for a checkup? | | | 29. Do you now have an appointment to see a 29. dentist? : ba oy 2 0 30. Do you think you have any teeth that need 9. 4 filling? y v : 1] Yes | 2] No 9 [] Don't know 31a. Do you think you have any teeth that need 3la. | -— to be pulled? VE IYes Asp i {skip to 320 : b. How many? b. | 1 [7] Some H 2] All T 32a. Have you ever had your teeth cleaned by a 32a. | 1] Yes — Ask b dentist or dental hygienist? ! 20] No — END OF INTERVIEW b. Wien hid the last time they were b. | 1] Less than | year ago Cleaner | 2[] 1-2 years ago | 3[7] 3-4 years ago : LC ! 4[]5 or more years ago . @ NOTES oz DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE FORM APPROVED PUBLIC HEALTH SERVICE O:M, 2, NO; S8-R1I24 A ETAL EA TH SDMINISTRATION ASSURANCE OF CONFIDENTIALITY - All information which would permit identification of the individual will be held strictly confidential, will be used HSM 425-16 HEALTH AND NUTRITION EXAMINATION SURVEY : : a only by persons engaged in and for the purposes of the survey, and will not REV, 471 be disclosed or released to others for any other purposes (22 FR 1687). DIETARY - 24 HOUR RECALL NAME: RESP. DATE OF BIRTH DATE AND 247 OF WEEK OF REGAL SAMPLE NO. SEGMENT SERIAL COLUMN CODE a7-22) "SEX" A A MONTH TE 1-5) (6-11) (12-13) TT (16) AY YEAR (23) (29-30) Gr 32) 3330) fe) HEEEEREEEEEER EERE 0 Orit O om PUNCH A NEW CARD FOR EACH FOOD ITEM FOODS AND BEVERAGES CONSUMED WORK AREA TIME | FOOD | LINE ING. FOOD CODE FOR OF CARD PER. FOOD ITEM DESCRIPTION COMPUTATIONS DAY | CODE | NO. 01 03 04 05 oe 07 os 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 RESPONDENT CODE “SEX” CODE (Use highest applicable code) INGESTION PERIOD CODE FOOD SOURCE CODE 1 - SAMPLE PERSON 4 - GRANDPARENT 1-MALE 5 - BREAST FEEDING 1- AM. 4-P.M 1+ HOME 3 - RESTAURANT 2 - SPOUSE 5 - COMBINATION OF ABOVE 2- FEMALE EXCEPT PREG. 6+ BREAST FEEDING/ 2 - NOON 5- TOTAL DAY 2 - scHooL 4- OTHER 3- PARENT 6- OTHER OR BREAST FEEDING PREG. 1-4 MOS. 3- BETWEEN MEALS 3 - PREG. 1-4 MOS. 7 - BREAST FEEDING/ P . 5-9 . 4 - PREG. 5-9 MOS. RES Ho's FAIVNNOILSIND T1VIIY INOH ¥T - AYV13Id "Oil XIANIddV Iz HSM-425-16 (BACK) (REV. 4-71) ING. p FOOD CODE FOOD ITEM DESCRIPTION - 41 INGESTION PERIOD CODE SIZE OF EDIBLE PORTION. SERVED FOODS AND BEVERAGES CONSUMED WORK AREA FOR ATIONS (If needed) FOOD SOURCE CODE COMPLETION CODE FOOD LINE SOURCE | CARD CODE NO. TIME OF DAY 34 35 36 37 38 1- AM 4-P.M 1 - HOME 1- COMPLETED SATISFACTORY 4-NOT AVAILABLE 2- NOON 5- TOTAL DAY 2- scHooL 2 - UNSATISFACTORY (SPECIFY) 5 - INFORMANT INC AP ABLE 3 - BETWEEN MEALS ES sumang 6- OTHER 4- OTHER 3- REFUSAL IS WHAT YOU ATE YESTERDAY (44) 1- YES 4- NO: SUNDAY OR HOLIDAY HAS YOUR DIET CHANGED RECENTLY? (45) 0 - NO CHANGE 3 - YES; EATING LESS THE WAY YOU USUALLY EAT? 2- NO: ILL 5- NO: OTHER REASON [] 1- YES; EATING MORE 4- YES; ON A PRESCRIBED DIET [] : NO MONEY (SPECIFY) ARE YOU TAKING VITAMINS ° "N° IF YES - INTERVIEWER - (See Guidelines) HOW MANY TIMES A WEEK DO YOU EAT wo] 0 - SELDOM, NEVER OR MINERALS? 1- YES, REGULARLY 1- MULTIPLE VITAMINS A MEAL AT & RESTAURANT? vets Tings 56) 2» VES: IRRECULARLY 2 - MULTIPLE VITAMINS AND MINERALS 8 - OTHER (SPECIFY) 2-4-6 TIMES [] Se IRONIONEY Sa dia [] 3-7 OR MORE TIMES 4- MULTIPLE VITAMINS AND IRON 8-N. A. INTERVIEWER: Ask only if respondent age 20 or over. (69) 0 - RARELY, NEVER (75-77) (79-80) HOW OF TEN DO YOU USE THE SALT SHAKER AT THE TABLE? 1- OCCASIONALLY, SELDOM INTERVIEWER'S CODE CARD NO. 2- FREQUENTLY, ALWAYS 8-N. A. (78) COMPLETION CODE [] ce DEPARTMENT OF HEALTH, EDUCATION, AND WEL FARE FORM APPROVED HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS O.M.B. NO. 68-R1184 ASSURANCE OF CONFIDENTIALITY - All information which would permit identification of the individual will be held strictly confidential, will be used only by persons. :ngaged in and for the purposes of the survey, and PUBLIC HEALTH SERVICE HSM 425-18 HEALTH AND NUTRITION EXAMINATION SURVEY S i REV. 4/71 will not be disclosed or released to others for any other purposes. . (22 FR 1687). NAME DIETARY ~ FREQUENCY BEGIN CARD NO. 1 RESP. DATE OF BIRTH DATE OF INTERVIEW SAMPLE NO. SEGMENT SERIAL COLUMN cope (17-22) ; "SEX" (24-29) f - 7 6-11) (12-13) (14-15) (16) [[ Mo. T oav | vear | (23) [ mo. | oav T vear | NO. OF INTERVAL NO. OF TIMES INTERVAL 1. MILK (BEVERAGE AND ON CEREALS) Es Gy © BREAKFAST CEREALS EITHER DRY AS ©6h oo WD, » pt a 2 CORNFLAKES OR COOKED SUCH AS OATMEAL LT] (66-67 { (35) 9. BUTTER AND MARGARINE ) g..py we 7 9 (33-34) 0 D1 w2 7 .9 90 IAB LTTTT] =k = hs Ww : 0 D1 w2 2 s 2. MEAT AND POULTRY G8) 10 rig om 3 er Sh Al Kinds sach as beefs pork; Yanibs (36-37) 0 D1 w2 7 9 cake, pie, cookies, puddings, ice cream veal, chicken, turkey, etc. 74) 11. “CANDY” (72-73) 0 D1 w2 7 8 - [TTT] 3. FISH OR SHELL FISH (39-40) 0 D1 W2 7 9 (79 - 80) LIT TT] CARDNO.1 [0 [1 _ (44) BEGIN CARD NO. 2 Repeat Columns 1-16 from Card No. 1 4. EGGS 42-43 0 DI w2 7 9 rr 12. BEVERAGES 17-18 0 TCR. @ A) COLD DRINKS, SUCH AS SODA, COLA, (47) (22) 45-46) 0 DI _wW2 7 9 5. CHEESE AND CHEESE DISHES 50 $1. COLD RINGS, AR ABOVE, ARTIFICIALLY ov we 7 i (50) (25) 6 DRY BEANS.AND PEAS lite (48-49) oO D1 we 7 9 ©) COFFEE OR TEA (23-24) 0 DI _w2 7 8 Pinto beans, red beans, black-eye peas, peanuts and peanut butter (53) 3 x 7. FRUITS AND VEGETABLES (51-52) o D1 wz 7 9 13. SNACK FOODS (potato chips, corn chips, (26-27) 0 D1 _w2 7 9 A) ALL KINDS - FRESH, CANNED, FROZEN, cheese snacks, etc.) COOKED, OR RAW, JUICES =m : (75-77) 79 - 80’ COMPLETION Al (56) INTERVIEWER'S CODE [ PLLT [ | CARD 02 8) FRUITS AND VEGETABLES RICH IN VITAMIN A (54-55) 0 D1 _w2 7 9 (See guidelines) NO. OF TIMES CODE INTERVAL CODE “SEX® CODE (Use highest applicable code) 00-NONE OR NEVER 0-NEVER 1-MALE 5-BREAST FEEDING 99-UNKNOWN 1-DAILY 2-FEMALE EXCEPT 6-BREAST FEEDING/ (59) 77-LESS THAN ONCE 2-WEEKLY PREG. OR BREAST FEEDING PREG. 1-4 MOS. (57-58) ° D1 w2 7 9 A WEEK 7-LESS THAN ONCE 3-PREG. 1-4 MOS. 7-BREAST FEEDING/ €) FRUITS AND VEGETABLES RICH IN VITAMIN C A WEEK 4-PREG. 5-9 MOS. PREG. 5-9 MOS. (See guidelines) } 9-UNKNOWN RESPONDENT CODE COMPLETION CODE (62) 1-SAMPL E PERSON 1-COMPLETED SATISFACTORY 8. BREAD (60-61) 0 D1 w2 7 9 2-SPOUSE 2-COMPLETED UNSATISFACTORY (SPECIFY) A) BREAD, ROLLS, BISCUITS, MUFFINS, CORNBREAD 3-PARENT 4-GRANDP ARENT + 3-REFUSAL = 5-INFORMANT INCAPABLE 5-COMBINATION OF ABOVE 7 SS oual 4-NOT AVAILABLE 6-OTHER HA FIVNNOILSINO ADNINOIYS - A¥VLIIA HII XIANIddV APPENDIX IJ. HEALTH CARE NEEDS QUESTIONNAIRE be held strictly confidential, will be used only by persons engaged in 0 10s she puipesee of te Sumer, and will not be disclosed or released HEALTH CARE NEEDS © others for any other purposes (22 FR 1687). HEALTH AND NUTRITION EXAMINATION SURVEY HIE (PAGE 1) Form Approved e's O.M.B. No. 68-R|184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE "ASSURANCE OF CONFIDENTIALITY | PUBLIC HEALTH SERVICE All information which would permit car HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION identification of the individual will a. Name (Last, first, middle) b. Deck No. | c. Sample No. d. Segment No. e. Serial No. f. Column No. 181 READ ~ | need to ask you a number of questions about doctors, dentists, hospitals, and other people who might give pe medical care, just how you them, and what your opinion is on some questions about health care. our answers will be kept confidential. peoocions ess | 'weris 6 but 2 5 1. When was the last time you talked 1. Never | M20 | through | thrush tess | through or to a doctor about your own health . . waka ve 2 — . more ve months vo |X years 20 oo ago os ago ago at a private doctor's office? . . 10 2] 30 a] s[J 6] Ee 10 2] 3] ad sO 6] 70 Lj 0 | 300 | «sO | sO | «OI | 703 at a hospital outpatient clinic? .. . at a city clinic? ..... BHA at a clinic at work? +. . vu ou ues 10 0 (so | «Ol sO | sO | "O Oo |lo|oflsm]|0]-o]-o 1d 20 J im] sO] se 7 at another type clinic? ......... at a hospital emergency room? . . . . 0 2] 30 + ss] sO ( vO 10 20 30 sd sO sO v0 eEO®O®®E6 over the telephone? . . . . in another way? — Specify 0 20 ( sd] «sO | sO | sO | »O 2. What was the MAIN reason for your 2. last visit with a doctor? (Check only one.) 1] A sickness or illness --What was the problem? ®|® 2[T] An injury-- What was the problem? 3] A follow-up visit a] A regular checkup 5 [J] An injection & [] For a prescription 7 [[] Some other reason 3a. For this last visit, how long was it 3a. 1 [[] Less than one day from the time you decided you should 2 [0] 1-6 dors see a doctor until you actually saw him: ts Wa HS 4[] 2-3 weeks s [7] 1-2 months 6 [] 3 months or more 9 [] Don’t remember . Did you have an appointment to see him? b. 1] Yes — Ask c 2[JNo — SKIP to 4 o n it from made ec. ost on Emma 3] 1 but less than 2 weeks 4[] 2-3 weeks 5] 1-2 months 6 [_] 3 months or more 9 [[] Don’t remember Was this time longer than you would d. 1] Yes have liked? 20INo 9 [] Don’t remember 4. From whot place did you leave to go 4 1 [7] From home to the doctor? 2] From work 3] From some other place 5. How did you get from there to the doctor? 5. 1 [7] Walked 2[_] Bus 3[] Own car 4 [C] Someone else’s car 5] Cab 6 [] Ambulance 7] Other means 6. How long did it take to get there? 6. + [J Less than 15 minutes 2[] 15-29 minutes 3] 30-59 minutes 47] | hour or more 9 [_] Don’t remember 7a. At this last visit, about how many 7a. minutes did you have to wait before being seen by the doctor? — — — minutes yr Do you think this wait was too long? b. 1] Yes 2CINo 23 24 : t 8. How well satisfied were you with 8 |! 1 [] Satisfied this visit? : 2] Not completely satisfied \ 3 [] Dissatisfied 4] No opinion 9a. During the past 12 months, have you 9a. _ i ty problem, which you would YE] You. Ask b have liked to see a doctor about but Tait for sume ToGo? 2 INoi=SK1p'ss 10 b. What was the reason you did not see b.i a doctor? ! ¥ ~ | es o Lack of confidence in available \ RIOTE wm n os imaarn rae aia sine nia | 0 200 i a : i Didn'thavetime ..........cu0uunnne ! 10 20 Would cost too much. «vv vvvuuneeunnnn 10 2] Couldn't get an appointment. . . . «....... 10 2] Would have to travel tos far... ous vs.s v3 2] Didn't have a way to get there . . ........ 10 20 Was afraid of finding out what Shi Ri i _ Didn't have anyone to care for ! children or other family members . . . . . y Id 27 | Other — Specify 10 2] 10a. When did you last have a general shedisp 10. 1 [] Never — SKIP to I3 or examination, not counting exams made durin 0 vse for wn Himeser 2 Less than Simuiiths 2g) 3[] 6—11 months ago 4[_] | but less than 2 years ago 5[] 2 years ago or more 9 [] Don’t remember 11. Where did you get this general sxeminetion? 11. 1 [7] Doctor's office 2[_] Hospital clinic ! 3 [7] Another clinic | 4] Some other place — Specify | 12. During this last general examination, were 12. you given — Yes No a cardiogram? . 1 20 a blood pressure check? 10 2 a chest x-ray? 0 20] blood tests? . . . J 20 a urinalysis? .. 0 20 Vision Aestel viv sun eR Es i ia Mm) hearing tests? | 1] 2] a rectal examination? . ........tani... } 10 203 i an internal examination (FEMALES ONLY)? . ! 10 20 & [] Not applicable | 13a. When ros the last time you received 13a. 1 [J Never — SKIP to 14 any shots, immunizations or vaccinations fo prevent an illness, excluding shots 2] Less than Gmonths ago for allergy? 3] 6-11 months ago 47] 1-2 years ago 5 [] 3-5 years ago 6 [] 6-9 years ago 7 [] 10 years ago or more 9 [1 Don’t remember b. Why did you get this shot? 5 1 [] Foreign travel 2 [] During military service 3[_] Participation in community or work- sponsored immunization campaign (for example, polio or flu) 4 [_] Other — Specify 4a. Is Sor a prtode docs a 14a. 1] Yes — Ask b regularly or whom you would go to something were bothering you? [No ~3KIP 10 15 b. If you couldn't see this doctor, is there b. 10] Yes some other particular doctor you would ol N want to see if something were bothering ! 2CNo ; you \ 9 [] Don’t know 15. Except in an emergency, do you need to 15. have an appointment in order fo 1] Yes doctor? 2 [J No 16. When you go to a doctor, do you like the 16. doctor to talk to you about your condition | 1] Talk or do you like him just to treat it? 2] Just treat 17. Do the doctors you usually see talk 17. 1] Yes to you about your condition? | 2No 18. Do you try out home remedies or any i A that you can get without a prescription | 1] Yes, often before going to your doctor about a \ 2[_] Yes, sometimes problem? ! 3sCINo NOTES ®0® at a hospital dental clinic? ... ata geval emergency clinic? = .......0.0... ® at another clinic (work, school, LN I ®@O®® in another way? ~ Specify DENTIST b: Do you have a dentist you ». 1] Yes usually go to? 2 [J No 20. When was the last time you 2. | visited or talked with a Less 6 Set 2 5 dentist about yourself. . . .. Naver then through less theodh | or months montis 2 years years ago ago years ago ago ago at a dentist's office?. ....... 10 2] 3d aJ sO s[J a 20 30 «0 sO) sO 10 27 3d ad J se] OO 20 0 ad sO) es] 10 2] 0 4} sO] sO OO 27 3d ad sO) es 21. What was the MAINreason for 21. your last visit or talk with a dentist at either his office or at a clinic? 1 [7] Adjustment or repair of dental plate 2[T] To have a dental plate made 3 [] Toothache 4] Tooth pulled or other surgery s[] Trouble with gums 6 [] Regular checkup visit 7 [J For cleaning teeth 8 [[] To have teeth filled 9 [] For a prescription 0 [[] Some other reason — Specify 22. For this last visit, how long was 22. it from the time you decided you needed or wanted fo see a dentist until you actually saw him? 1 [] Less than one day 5[] 1-2 months 2[] 1-6 days & [] 3 months or more 3 [J | week but less than 2 weeks 9 [7] Don’t remember a[] 2-3 weeks 230. At the time of this lost visit or talk with a dentist did you have an appointment? b. How long was it from the time you made the appointment until you saw him? c. Was this wait longer than you would have liked it? 2a. 1] Yes — Ask 23b 2] No — SKIP to 24 b. 1 [] Less than one day 2[] 1-6 days 3] | week but less than 2 weeks 4] 2-3 weeks 5] 1-2 months 6 [] 3 months or more 9 [] Don’t remember 5 @D) 1 [Yes 2[JNo 9 [] Don’t remember 24. How did you get to the dentist's office’ 24. 1] Walked 2 [] Bus or subway 3[J Car 4] Cab s [] Other means — Specify -. 25. How long did it take to get there? 2. 1 [J Less than 15 minutes 2] 15-29 minutes 3 [J 30-59 minutes 47 | hour or more 9 [] Don’t remember 27. How well satisfied were you with this visit? * | | | | | 26a. At this last visit with a dentist, 2a. | sloavy how Woy minutes did 2 i ave to wait re being seen by y the dentist? ! __ ____ minutes b. Do you think this wait was too long? bo 1) 10 Yes | 2[JNo 7. i 1 [] Satisfied | | 2] Not completely satisfied 3] Dissatisfied 4] No opinion 28. Does your dentist or dental clinic call you or send you a note to remind you when your next regular checkup is due? 28. 10 Yes 2[JNo 9 [] Don’t know Didn't have time . ..... Would cost too much ........ Didn't have anyone to care for Some other reason . . ... crane Couldn't get an appointment . ........ Would have to travel too far ..... [Er Didn't have a way to get there . . . . . . .. children or other family members . . . . . 2a. Busing J a 12 manihe; ove you be had Da. a dental problem which you wou Yes — liked to see a dentist pl but you po } A (J ¥es ~ Asie 200 see the dentist? 2] No — SKIP to 30 29b. Why didn’t you see him? 2b. Yes No m0 20 . @ Oo 2] @ 0 20 . @O 20] @ 0 20) : @ 10 2] 25 26 HOSPITAL 30. When was the last time you stayed in a hospital overnight or longer? 1 [] Never — SKIP to 36 2[] Less than | month ago | 3] 1-5 months ago 4] 6-11 months ago 5] One year ago or more 9 [] Don’t remember 31. Was this stay in the hospital on account of an emergency or was it planned in advance? 3 1] Planned 2 [] Emergency 32. What was the MAIN reason you went into the hospital that time? 32. 1 [] Sickness or illness 2 [] Injury 3] Surgery 4[C] Child birth s [J] Checkup 4 SKIP to 34 6 [] Some other reason — Specify and SKIP to 34 33a. When you went into the hospital for this. , just what was the problem? b. How long was it from the time it was decided you needed to go into the hospital until you went in? - = 1 Less than one day 2] 1-6 days 3[] | but less than 2 weeks a] 2-3 weeks 5] I-2 months 6 [_] 3 months or more 9 [] Don’t remember 340. What part of the doctor's bill did you or your family have to pay out of your own pocket for the treatment the doctor gave you while you were in the hospital? b. Did you get any of this money back from your health insurance? ’ 1 [CJ] None — SKIP to 35 2[] Less than half 3 [] More than half, but not all aJ Al 9 [] Don’t know — SKIP to 35 1] Yes 2] No | I | | | | | | I | | | | i | | | | i y | | | | | | | | L 35a. What part of this hospital 35a. 1 bill did you or your family | @ have to pay out of your own pocket? 1] None — SKIP to 36 2[] Less than half 3 [J] More than half, but not all a] All 9 [] Don't know — SKIP to 36 b. Did you get any of this money _ b. back from your health insurance? 1 Yes 2[]No 36a. 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? 1] Never been to a doctor — SKIP to 37 2[_] None — SKIP to 37 3[] Less than half 4 [] More than half, but not all s[] Al 9 [] Don’t know — SKIP to 37 b. Do I get any of this money b. back from your health insurance? 1] Yes 2[] No 37a. Whenever you see a dentist Fa. 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 pocket? 1 [] Never been to a dentist — SKIP to 38 2 [_] None — SKIP to 38 3[] Less than half 4] More than half, but not all s[J Al 9 [] Don’t know — SKIP to 38 b. Do you got ony of this money _ b. back from your health insurance? | { 1] Yes 2[JNo ' “ 38a. What part of the cost of drugs 38a. | ©) and medicines prescribed by } your doctor do you pay out of your own pocket? 1 [J 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 sCJ All 9 [J Don’t know — SKIP to 39 10 Yes 2[]No b. Do you get any of this money _ b. hrm Ode A 39. Do you have insurance or 3. coverage for medical care under... . Medicare (for elderly)? RD), Private medical insurance?. . . . . LD) Insurance through your place of work? | Veterans medical core? ....... I Some other government assistance program? — Specify | 1 Py —" SS g @ 1 39b. What part of your medical bills does it pay Less | More than Yes No rin half but All Don’t know al not all i] 2) 3d sO [7 2] 3} ss 1d 2] 3d 3) 10 20 3d od +] 2] 0 od "0 2] sO sd 10 2] 30 oJ 10 2 10 2 : 8 ili | 2] 0 @EReER® 0 a ® +] 2] i] oJ APPENDIX IIK. GENERAL WELL-BEING QUESTIONNAIRE HSM-411-T (pace 1 8/71 REV. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION NA TIONAL CENTER FOR HEALTH STATISTICS HEALTH AND NUTRITION EXAMINATION SURVEY GENERAL WELL-BEING Form Approved 0.M.B. No. 68-R|184 ASSURANCE OF CONFIDENTIALITY All information which would permit 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). “la. Name (Last, first, middle) b. Deck No. | c. Sample No. d. Sex e. Age 1 [[] Male V1 | cen 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. How have you been f. THE PAST MONTH) ling in general? (DURING Ll @ 1 [In excellent spirits 2[_] In very good spirits 3] In good spirits mostly 4[] 1 have been up and down in spirits a lot s[] In low spirits mostly 6] In very low spirits 2. Have you been bothered by nervousness or your “nerves”? (DURING THE PAST MONTH) 2 1 i | | | | 1 | 1 | | 1 1 1 [_] Extremely so -- to the point where | could not work or take care of things 27] Very much so 3] Quite a bit 4[_] Some -- enough to bother me s[]Alitle 6 [] Not at all 3. Have you been in firm control of your behavior, thoughts, emotions OR feelings? (DURING THE PAST MONTH) 1 [] Yes, definitely so 2[] Yes, for the most part 3] Generally so 4] Not too well s[]No, and | am somewhat disturbed 6 [_] No, and | am very disturbed 4. Have you felt so sad, discouraged, hopeless, or had so many problems that you wondered i anything was worthwhile? (DURING THE PAST MONTH) 1 [] Extremely so -- to the point that | have just about given up 2[] Very much so 3] Quite a bit 4[_] Some - - enough to bother me s[] A little bit 6 [J Not at ail 5. Have you been under or felt you were under any strain, stress, or pressure? (DURING THE PAST MONTH) 1[7] Yes -- almost more than | could bear or stand 2[] Yes -- quite a bit of pressure 3] Yes -- some - more than usual a[_] Yes -- some - but about usual s[] Yes -alittle 6 [| Not at all 6. How happy, satisfied, or pleased have you been with your personal life? (DURING THE PAST MONTH) 6. 1 (9 1 [] Extremely happy — could not have been more satisfied or please: 2] Very happy 3] Fairly happy 4 [7] Satisfied -- pleased 5 [] Somewhat dissatisfied 6 [] Very dissatisfied 7. 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) 1 [] Not at all 2[_] Only alittle 3[] Some -- but not enough to be concerned or worried about a[_] Some and | have been a little concerned 5[_] Some and | am quite concerned 6] Yes, very much so and | am very concerned 8. 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 5] A little bit 6 [_] Not at all 9. Have you been waking up fresh and rested? (DURING THE PAST MONTH) 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 isorder, pains, or fears about your health? (DURING THE PAST MONTH) 10 1 [7] All the time 2] Most of the time 3[_] A good bit of the time 4[_] Some of the time 5[] A little of the time 6 [_] None of the time 11. Hes your daily life been full of things that were interesting to you? (DURING THE PAST MONTH) 11. 1 [J All the time 2 [] Most of the time 3[_] A good bit of the time 4 [_] Some of the time s[] A little of the time 6 [1 None of the time 12. Have you felt down-hearted and blue? (DURING 12. THE PAST MONTH) 1 [7] All of 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 27 28 13. Have you been feeling emotionally stable and sure of yourself? (DURING THE PAST MONTH) 13.4 All of the ti L@ 0 of the time 2 [_] Most of the time 3 [C] A good bit of the time a] Some of the time 5[_] A little of the time 6 [_] None of the time 14. Have you felt tired, worn out, used-up, or 14. exhausted? (DURING THE PAST MONTH) 1 All of the time 2 [] Most of the time 3] A good bit of the time 4[_] Some of the time 5] A little of the time 6 [] None of the time 15. How concerned or worried about your HEALTH 15. ! have you been? (DURING THE PAST MONTH) 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. ® 2 5 * . a ’ . . . 10 Not Very concerned concerned at all = ® ° " “ - - - ~ - - 5 16. How RELAXED or TENSE have you been? 1 (DURING THE PAST MONTH) Very Very relaxed tense 17. How much ENERGY, PEP, VITALITY have 17. you felt? (DURING THE PAST MONTH) ® - - @ - " - » - - 3s No energy Ve AT ALL, ENERGETIC, listless dynamic 18. How DEPRESSED or CHEERFUL have 18. have you been? (DURING THE PAST MONTH) ® 2 3 4 5 6 7 8 9 10 Very Very depressed cheerful 19. Have you had severe enough personal, 19. emotional, behavior, or mental problems that you felt you needed help DURING THE PAST YEAR? i | | | | 1 1 | | 1 T | 1 | 1 | i | 1 i | | | | i | | | | | | | i 1 1 1 | | | | | | L I i i | | I | i t | | | | i 1 | i | | | | | | | | | | i 1 1 i 1 1 1 | | | | | | 1 | i 1 | 1 1 I | | 1] Yes, and | did seek professional help 2] Yes, but | did not seek professional help 3] 1 have had (or have now) severe personal problems, but have not felt | needed professional help 4] 1 have had very few personal problems of any serious concern 5] 1 have not been bothered at all by personal problems during the past year 20. Have you ever felt that you were going to 20. 1 [J] Yes -- during the past year have, or were close to having, a nervous 2[] Yes -- more than a year ago breakdown? 3] No 21. Have you ever had a nervous 21. 1] Yes -- during the past year breakdown? 2[] Yes -- more than a year ago 3[JNo | | 22. Have you ever been a patient (or outpatient) 2! 17] Yes -- 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.’ 2] Yes -- more than a year ago 3[ No 23. Have you ever seen a psychiatrist, Vaycholagisy, 2. or psychoanalyst about any personal emotional, behavior, or mental problem concerning yourself? 17] Yes -- during the past year 2[] Yes -- more than a year ago 3[JNo 24. Have you talked with or had any connection with any of the following about some personal, al, behavior, mental problem, worries, erves’’ CONCERNING YOURSELF DURING THE PAST YEAR? a. Regular medical doctor 24a. except for definite physical conditions or routine check-ups). ........ b. Brain or nerve specialist ............. b. c. Nurse (except for routine medical conditions) . ....... iia. ec. d. Lawyer (except for routine legal services) «vo o.vounenn. Ces i e. Police ( except for traffic violations) . . e. f. Clergyman, mi rabbi, etc. . . . f 9. Marriage Counselor ..«....... Forwinin a he. Sociol Workers + cov vvsvvvnnrnnvrmns h. i. Other formal assistance: © 1] Yes 2[JNo @) 1] Yes 2INo @ ves 2[]No @) 1 [Yes 2[JNo ©) 1 [0] Yes 2[]No @) 1] Yes 21 No ©30) 1) Yes 2 No @D) 1 Yes 2[]No L@ 1 [0 Yes — Whot kind? 2[JNo 25. Do you discuss your problems with any members 25. of your family or friends? 1 [J Yes - and it helps a lot 2[] Yes - and it helps some 3[7] Yes - but it does not help at all 4[] No - | do not have anyone | can talk with about my problems s[] No - no one cares to hear about my problems 6 [_] No - | do not care to talk about my problems with anyone 7 [J No = | do not have any problems 26. Filled out by: 26. © 1 1] Examinee 2] Interviewer 3 [| Mixed APPENDIX IIL. SUPPLEMENT A HSM-411-2 (pace 1 REV. 8/71 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 A — ARTHRITIS Form Approved 0.M.B. No. 68-R1184 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). Name (Last, first, middle) Deck No. Sample No. JL. | ewer mice 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 Ta. on most days for at least one month? 17] Yes = Ask b 2] No — SKIP to 2a T J | i b. Has this pain in the back or neck been ba 1] Yes present on any one occasion for at least } 2[)No six weeks? | & Where is the pain usually located? ef Yes No Tp | [fm] 20 Upper backs = ois + sein si onaieie sami wa ! ial 2] | MIBIBRER: sian ibid Hess SR Tv i | 10 20 Lower back owerback......... iii i 20 d. When you have this pain, where is it most intense? d.| Yes No NER cin win Toss Tile mins Rede oe Bae Sit BF | 1 2 a a UppRr hoe: «i vine sak sin sie 8 5 800 2e oe 10 2) | MIBBEERS 5s is Hh Haih SE SE THE Ti ; 2 i i 10 a Cowes back un sie um fk SE.805 Buin : 10 20) e. Is the pain present when you are resting . 1] Yes at night? 2[INo f. When you have the pain, does it awaken f. 1] Yes you from sleep at night? I 2] No | g. Does the pain in the back ever seem 9! 10] Yes to spread? } 2] No i 3[] Not applicable, no pain in back h. Where does it spread to? hoi Yes No To the back of the right leg . ............ | 10 2] | To the back of the left leg . ............. ! 10 2] Fo the bach ob bothilesy: + siiv uns pHEEEES i OO 20] To the top of the head . . .............un ! 10 200 | To the sides of the body ............... | 10 20 1] Yes i. Has pain in the neck ever seemed to spread? ¥ 2[No 3[] Not applicable, no pain in neck | | i i i | i. Where does it spread to? jo! Yes No 1 To the top and back of the head. . .. ...... ! 10 2] i To either shoulderarea . .......cuuuens ! 10 200 1 To the arms or hands. . . .....ouniinns ! 10 200 i her — § | iC Other — Specify. | Od 2] T k. Is your back or neck pain made worse — ke! Yes No by coughing, sneezing, or deep breathing? . . . | im] 200 | 1 with bending or twisting motion? .. ....... | 10 2] i after prolonged activity? .. ......etinnn | 10 2] | after prolonged sitting? . .............. ! 10 20) ft | d standing? . « «vv nna ens 1 2 after prolonged standing i} O I. How old were you when you first experienced 1. 1 [J] Less than 20 years old this recurring back or neck pain? 2[]20 — 29 years old 3[]30 — 39 years old [7] 50 — 59 years old 6 []60 years old or older 4[]40 — 49 years old m. When was the last time you had this pain? m. 1] Now 3[] 1 —2 years ago 4[]3 — 5 years ago 5] 6 years ago or more n. What is the longest episode of back or n neck pain you have ever had? | | 1 1 | 1 i 1 1 I i 1 1 | 1 2[] Less than | year ago but not now 1 | | i 1 1 1 1 f 1 1 i i i | i i 1 1] Less than one month 2[_] One but less than two months 3[]2 — 3 months .[] 6 months or more 4[_]4— 5months 9 [_] Don’t remember o. Does this back or neck pain sccur more ol 1] Yes frequently now than it used to occur? ! = i 2 [J No f P- Have you ever had o sprained back due to pl 10] Yes + i ivity? some type of physical activity ! 20] No q. Have you ever had a “‘whiplash’’ injury q. 1 Yes of the neck? 2 o 29 30 Have you ever had a ruptured disc in either your back or neck? . At what age? 1 [] Yes — Ask s 2 [No SKIP tov 2 ® © © i YORE t. Were you in traction? t. 1 [] Yes 2 [No u. Was surgery necessary? wi 1 [Yes } 2 [No T v. Have you ever stayed overnight in a hospital v! 1 [C] Yes for back or neck pain? i 2 CINo : 2a. Have you had pain in or around either hip joint 2a. | 1 [] Yes — Ask b (including the buttock, groin, and side of the | ~ rer hor} a eet dave for of Tevet one ’ 2 [J No-SKIP 16:39 month? be b. Has this pain in the hip area been present on b. | 1] Yes any one occasion for at least six weeks? 4 2 Iw ! . ¢. Where did you first notice it? el v [] Left hip | 2 [J Right hip ! 3 [_] Both hips d. In the hip area, where is the pain usually dl most intense? Yes No Right buttoekis. « o.o.4 5 4s 04 #3 CAMRY | 9 | 10 2 Leftbuttock oan sensvasninsnn oes | 2 = tl Both buttocks. «vss suv vu sanvans wn | 10 2] oth buttocks. i a 2 : ; | Right groin + ...uuss gia we i Yl 2] Lefbigroin ovis veins TR | 2 eft groin i +73 3 Both groins «viv ven vn vv ream | @®) 1 20 oth groins C=] 0 Side of right High: 56% swan swans Le Od ry | Side of left thigh, . ....... Gwe ok ; cf 2] | Sides of both upper thighs. . +. vv voveuss | 10 200 | Other — Specify. | 1 20] i e. From the hip, has the pain tended to spread to — e. ) Yes No the inside of your leg?..... aR a, re ! 10 20 | the front of your leg? + ...uuun Veena 4 1 (0 20 | the outside of your leg? «vu uuu vines ! 1 2] | the back of your leg? +. .u.uu.s OR | TO 2] f. Have you had pain in or around the hip when | 1 [7] Yes either coughing or sneezing? ! 2] Ne g. When this hip pain is present, does it o| 1] Yes hurt at rest as well as when moving? 2 [Ne ! J h. How old were you when you first h. 1 [] Less than 20 years old experienced this recurring pain 2[]20 — 29 years old 3[7]30 — 39 years old 4[]40 — 49 years old 5 [7] 50 — 59 years old 6 [_]60 years old or older i. When was the last time you had the pain? i 1] Now 2[_] Less than | year ago but not now 3[T] 1 — 2 years ago 4[_]3 — 5years ago 5[_]6 years ago or more is i» What is the longest episode of hip pain [7 1 [7] Less than ene month you have ever had? i 2] One but less than 2 months ! 3[]2 - 3 months 4[]4 — 5 months s [_] 6 months or more 9 [7] Don’t remember k. Have you ever had a fractured hip? k. 17] Yes — Ask | 2[7]No — SKIP to p I. Which hip was broken? 1 1 [J Right 2] Left 3[] Both m. How old were you when it happened? m. (©) _ — Years n. Was the hip in traction? n 1] Yes 2[_| No o. Was there surgery? o. 107] Yes 2[_1No p. Have you ever had a dislocated hip? pe 1] Yes — Ask q 2[7] No — SKIP to 3a q. Which hip was dislocated? q 1 [7] Right 2] Left 3[] Both r. How old were you when it happened? rn _ _ Years s. Was the hip in traction? s. 1] Yes 2[ No t. Was there surgery? t 1] Yes 2[ No 3a. Have you had pain in or around the knee So. | 17] Yes — Ask b (including the back of the knee) on most | 20] No = SKIP to 4a days for at least one month? ! is b. Has this pain in the knee crea been present b. 17] Yes on any one occasion for at least six weeks? 2[ No 3c. In which knee did you first have if? 3c. | 1 [0] Left knee I 2 [] Right knee | 3 [] Both knees ! 9 [_] Don't remember d. How old were you when you first experienced d. | 1 [7] Less than 20 years old recurring pain in the knee? ! 2 []20-29 years old ! 3 [] 30-39 years old 1 4 [] 40-49 years old ! 5 [] 50-59 years old ] 6 [] 60 years old or older L e. When this knee pain is present, where is it e | Yes No most intense? | Right knee . ...... testers raanens © @ [J 20 | Leftknoe «ovovnannnnnesisanen | @) 1] 20 Both Knees suis cvnmnvenmn rnin N— l@ Oo 20 Behind the right knee .......o0ouuuananann ®) 10 20 Behind the left knee ....ouiun.n sseissesnies Od 20 | Behind both knees +. ......... veers i @ 10 2J f. When this knee pain is present, does it hurt fF. | 1 [0] Yes at rest as well as when moving? | 2 [No g. When this knee pain is present, is there also e | 1] Yes swelling of the knee joint? ! CINe h. When this pain is present, have you every had h. | 1 [Yes “locking of the knee ! 2[ONe i. Has either knee ever ‘‘given way'’ under you? i. | + [Yes — Ask | ! 2 []No —SKIP tok | i. Which knee? ood + [] Right ! 2 [Left 1 3 [[] Both Kk. When was the last time you had this knee pain? k. | 1 [7] Now l 2 [7] Less than | year ago but not now i 3 [[] 1-2 years ago : a [] 3-5 years ago ! s [_] 6 years ago or more I. What was the longest episode of knee pain you I. | 1 [] Less than one month have ever had? | 2 [] One but less than 2 months | 3 [_]2-3 months | 4 [] 4-5 months 5 [] 6 months or more | 9 [7] Don't remember : m. Have you ever had a fractured knee? m | @) 1 []Yes—Askn : 2 [] No — SKIP too n. Which knee? nl 1 [7] Right } 2 [] Left | 3 [_] Both o. Hove you ever had a severe twisting of i 1 Yes — Ask p either knee with resultant sprain or swelling 2[JNo—SKIPtogq lasting more thon two weeks? p. Which knee? p. 1] Right 2] Left 3[_] Both 4 Have you ever had any other knee injury? q 1] Yes — Ask r 2 [7] No — SKIP to 4a r. Which knee? n 1] Right 2[] Left a[] Both 4a. Have you ever had hip, knee, or back 4a. 1] Yes — Ask b disease treated by an operation? ! 2[7] No — SKIP to 5a i b. Which joint? bo | 1+ [J Hip 4] Hip and knee 2[7] Knee 5 [7] Back and knee 3 [7] Back 6 [] Hip and back IF HIP: TOIALL (1) Which hip? n 1+ [7] Right 2] Left IF KNEE: ! 3[] Bon (2) Which knee? 2 | 1 [Right ! 2 [7] Left } 3[] Both c. What was the operation or procedure? i 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 21] No ~ SKIP 0 6a days for at least six weeks? id b. Which joints were painful? b.&c. [=| Be. If “Yes.” ~ Which? Yes No Right Left Both Fingers: sos soa slots Se Aish 538 KET & 10 203 OO 20 0 WOISE, vic wiwie ih Be 0% HE RS WINS § @ 0 200 10 20 0 Elbows ovis wor we 4ih wus iwi WE HATE 7 @) 1 200 10 20 0 SHORE suis iy sin sea we BD 4 WY 4) OO 0 ARIS cn out siti 35070 ww end AS AR THE @ 0 20 10 20 0 FOotcom sis wins six suman wis Hew TO 20 | 0 20 sO 6a. Have you ever had any swelling of joints 60. (1) 1[]Yes—Askb with pain present when the joint was touched 1 2 No — SKIP to 7a on most days for at least one month? ! - b. Has this swelling been present on any one bet 1) 1 [Yes occasion for at least six weeks? § 2 OJ No 31 32 r 6c. Which joints are usually involved whenever 6c.&d. | Yat hi Msadtimnpebiiniddy rl ibid | = [68 4 "Yes," m Wilh? touching? | Yes No Right Left Both BATGRIE ovr ceamsvom vom se Bonn San em | @) vw] 20 @ vi 2) =] WIFE. ra sri oa wom wR peu Arena 0 20 | @ 0 0 0 Elbows. . 10 200 10 20 $0 Shoulders . oo. ouiii aes @ 0 0 |@ iO 0 sO Wp: vi vit nis evi aE aE ies wins 4 @ 0 0 | @ 0 0 0 RIRES wv siere mie Seevervepcarwsmsers wimon snares @ Oo 0 |@® 0 0 0 Bolles =is 555 wos oka EE EHR VEE SW 6 @ 0 0 |@ 0 0 0 WI00K) werner suse somone on sn sn 1 @ 0 20 OI 2 sO) Ge. How old were you when you first experienced e. 1 [J Less than 20 years old this swelling of the joints? 20720 — 29 years old 3[]30 — 39 years old 4[] 40 — 49 years old 5 []50 — 59 years old 6 [_] 60 years old or older f. When was the last time you had this? £1 @) 1 [Now 2[] Less than | year ago but not now 3[] | —2 years ago 4[]3 —5years ago : 5[_] 6 years ago or more 7a. Have you had stiffness in your joints and To! @) 1 Yes-Askb muscles when first getting out of bed in 2] No — SKIP to 8a the morning on most mornings for at least one month? b. Has this morning stiffness been present on bi (3) 100 Yes any one occasion for at least six weeks? 2 No | c. Which joints are usually involved whene c.&d. ity i; you have this morning stiffness? 7d. If “Yes,” — Which? Yes No Right Left Both MOORE si wis i A 0 a | @ 0 20 | @ 0 20 =O Wrists GO 0 | @ a 0 0 Elbows 0 20 YO ‘203 sd Shoulders 0 20 | @ 0 20 =O Hips @ 0 20 | @ 0 20 0 | Knees I 0 20 | @ 0 20 0 | Ankles 1 ® 0 20 |@ 0 0 sO Feet | @ 0 200) WO 200 3s] B ack | Oa 200 e. How long after getting up and moving e.! (5) 1] Less than I5 minutes around does the morning stiffness last? 2[_] 15 minutes to one half hour 3 [J More than one half hour but less stiffness which might still be present, do you think? 2[JNo s [7] Don't know than all day a [CJ All day f. How old were you when you first experienced f.1 (15) 1] Less than 20 years old this morning stiffness of joints? . 207120 — 29 years old 3] 30 — 39 years old 4[] 40 — 49 years old 5[_]50 — 59 years old 6 [_] 60 years old or older g. When was the last time you had this? gi (59) 1 [Now 2] Less than | year ago but not now 3] 1 — 3 years ago 4[]4-9 years ago 5 [] 10 years ago or more 8a. Hove you ever had pain, swelling, or stiffness 8a.| (59) 1 [Yes — Ask b in a joint ay the result of an accident or injury? 2] No — SKIP to 9 b. Was this the cause of the pain, swelling, b. 1] Yes or stiffness mentioned previously, do you think? 21% 9 [] Don't know c. Is this the cause of any pain, swelling, or el BD ives Have you ever been treated by any of the 9. following people for your joint troubles? General practitioner. . ................. Intormist oc anni sn sane Rheumatologist Orhopedist . «ov vivvivimivwivinin mins wim ives Chiropraetor ois + vi va oii GRE AER Sos HAE ! OFOORIING, vv 40 wink wc dsc wre win Deiws 250 0 Foot doctor (chiropodist or podiatrist). .. .... Physical therapist ................... Occupational therapist. ................ Other — Specify Never been H8u10d vis veiw wivmivrvis warner Yes No 0 20 a 2] a Hm! 10 2] 1d 2 0 2] i 2] a 20 0 2 10 2] s[ISKIP to lla 10a. Are you currently being treated by a doctor 1 for the troubles you have just described? b. What type of doctor is he? c. What did he say the problem was? c 1[]Yes — Ask b 2[JNo—SKIP to lla 1 [] General practitioner 2 [] Internist 3 [_] Rheumatologist 4 [_] Orthopedist s [_] Chiropractor 6 [_] Osteopath 7 [_] Other specialist 8 [] Other — Specify. DATA PREPARATION USE ONLY 1 @ 0 10 @ OJ 0 10 d. When was the last time you saw him? e. Who originally referred you to this doctor? f. Where do you usually see him? g. How long will it be until your next visit to him? QOO®6 1[] Less than | month ago 2[] 1 — 3 months ago 3[_]4 — 6 months ago 4[_]7 — 11 months ago 5] | year ago or more 9 [] Don’t know 1] No one 2] He's the regular doctor 3[_] Another doctor a] Family s [J Clinic 6 [_] Health nurse 7 [] Friend 8 [] Other — Specify. 1 [J His office 2 [J Ata clinic 3 [] At home 4] Other 1] Less than | month 2[]1 — 2 months 3[]3 — 6 months 4[J7 = 11 months s[_] | year or more 9 [] Don’t know 11a. Have you ever used any of the following ilo. «| 1b. Did it do you inds of treatment for your joint troubles? ! any goed? : Yes Yes No i | - Spliisorcosts : vas uaa won Sa wes oe | 10 1 2(] | BrOCeS . vee L@® 0 @ 0 2] | Diathermy or paraffin. . ..... o.oo... .. | 10 10] 27 Hot packs or heating pads. . ............ : 0 Ol 2 ot packs or heating pads L@ Oo | a | - Cold packs orice... oor. i i 10 20 | Rest i vio inn sew simile $46 SoG Ka in 1 1 1 20 LC PU 0 Wy 2[] Exerc hysical therapy . . . ........ 1 ' 2[C xercises or physical therapy 0 0 0 A 1 10 1d 2 0 oO 1d 1 2 ®C oO SHEE Mat 7088. Lotte eae iff mat ress 1 @ 0 @) 10 2] Bed Boards wns wii vv seas ey sin #9 10 [im] 2 c. If “Yes” to lla or 1b Do you use it regularly? c. Yes No Splints-or casts «o.oo uiiiii 10 2] BIGERYS vio hina vom inman sihitcme mope-gaiscone 10 2] Diathermy or paraffin. . . 10 2] Hot packs or heating pads. . | [eD) 10 2] | Cold pagky oriiee ou. i vue Sap 4 Lam ane \ old packs or ice r@ 0 2] Rest cu vuoi nan ronson vs dessa as | @ +) 2] Traction uv vn vas ve ian snmens sass @ 10 2] Exercises or physical therapy . .......... 10 20) ASPIRE ois orvini vw iwmi dks od WR eR 9 @ i | 27) CRB ve wie doe THR UR RR i 0 =O CTU scons wm cow nw im cn § Ro asin 4 1 2 1@ 0 uo SHE MOIIES vv vive vivivceiimim ene vim cae 1 2] Bed board... oo outiii i i] 20 120. Have you ever had injections into any 120.) @) 17] Yes - Ask b of your joints? i 2[7] No — SKIP to 13a | b. Did they do you any good? bi @) ives | 2[]No 33 34 T 13a. Have you ever taken any of the following 13a. | Yes No Don’t know, medications for your joints? | Any cortisone-like medicine by mouth . . . . . | @ 0 21 sO] i EUR OHI tei vimivim ie eis ramon amis i 10 2 oC ] @ 0) 0 Cc Darvon or Tylenol... ..o.vuuunnn.. Nm) 23 s | @ to oO EAETEI vitesse Rie 4 ae i ATRL ! @) tL] 2] so] be If “Yes" — Did it do any good? b. | Yes No Any cortisone-like medicine by mouth . . . . . ! 0 2] | Butozolidin «vs vos sais vain wn ive sis | 1 2] | @ 0 tl Darvon or Tylenol. . oo. .vvninnens i nl 203 LT, | 10 2] 14. Can you do the following things without 4. | the help of someone else or the help of i some special device? ! Yas ho Go up or down stairs . ..............s ! 10 200 i Get intooroutof a car .......uuuun.. ' @) 0 2] i Use washing facilities. .............. v @ iP 23 i Dress Joust «vcs + wv vin wiv iivmnn es '@ 0 2] i Foedyoursell cv vaviiies wnsmimvmininis vn | @) 1 2] Get into or out of bed... ..... oi... L@ 10 21] 15. At the present time, does your joint 15. | 1 [7] Very little condition restrict your physical activity | 2] Quite a bit very little, quite a bit, or a whole lot? } ! 3] A whole lot | 16. Have you ever had to stay in bed at home for 16. | (@3) 1[] Yes long periods of time because of your joints? | 2 No 1 17. Have you ever stayed overnight in a | 1] Yes hospital because of joint problems? ! 20 1No i 18. With respect to your joint trouble, would 18. | 1 [CIMild you say your condition is mild, moderate, | 2 [] Moderate or severe? { z | 3 [| Severe } 19. What was your job status one month before 19. | 1 [7] Retired because of age you first developed your joint condition? 2 [7] Retired because of disability 3 [| Unemployed 4 [] Working full-time 5 [| Working part-time 4 6 [] Housewife with full duties | 7 [] Housewife with partial or no duties | 8 [| Other — Specify 20a. As a result of your joint condition, has 20a. [D) 1] Yes — Ask b there been a change in your job status? 2] No — SKIP to 21 b. What is it now? b. @) 1 [] Retired because of disability 2 [_] Unemployed 3[] Changed to easier job 4 [] Working 5 [_] Housewife with partial duties ! 6 [_] Housewife with no duties | 7 [7] Other — Specify 21. How many work doys do you estimate that 21. | @) 1 [None you lost during the past 12 months as a result of your joint condition? 20] I= ders 3[] 5- 9days a[]10 — 14 days s[]15— 19 days 6 [7120 — 29 days 7 [] 30 days or more APPENDIX [IM. SUPPLEMENT B HSWM-411-3 (Pace 1 REV. 5/71 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE UBLIC HEALTH SERVI Health senvices AND MENTAL HEALTH TIONAL CENTER FOR HEALTH ST ADMINISTRATION ATisTICS Vanann AND NUTRITION EXAMINATION SURVEY SUPPLEMENT B — RESPIRATORY Form Approved 0.M.B. No. 68-RI 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). a. Name (Lost, first, middle) b. Deck No. c. Sample No. Bl | eam READ ~ Earlier you mentioned havin had either persistent cough, ay fever. Here are some Yi questions about this phlegm, wheezing, shortness of breath, asthma, or trouble. > PERSISTENT COUGHING 1 [7] Yes — Ask b la. Was your problem that of persistent coughing? la. 2 [7] No — SKIP to 2a b. How long have you had this condition? 5 1 [T] Less than | year 2 [7] 1-3 years ! 3 [7] 4-9 years | 4 [7] 10 years or more L I ¢. Have you been bothered by this within the e } 177) Yes past year? 1 2 1No d. When you have this trouble, do you also 4 | 1] Yes — Ask e have chest pains? 1 = i 2 [No —SKIPtof e. Where? a: i Yes No jC Se OF Sf 0 | 2] Lowerback . «oun el er Od 2] | Ura lai civces sions wikis ie — 1 [J 2 | Along the rib edge + .........iinin | 2] On the sides +. ........... wenn y (@ 1 2] %. Do you bring vp phelgm with the cough? Lo 1 [] Yes : 2 [No I - + Do you cough persistently like this on 9 | 1 [7] Yes most days for as much as THREE ! 2-1 2 [C1 No months each year? ' ! h. Do any medicines you take help relieve ho! 1] Yes the cough? ! pe 2 [No | i. What time of year do these coughing Wl 1 [7] Winter attacks seem at their worst? } “1s % 2 [] Summer ! 3 [7] No difference | 20. Have you had trouble with coughing spells when 2a. | you first get up in the early morning? (Count | _1Yes — Ask b a cough with first smoke or on first going out | 2 [J No — SKIP to 3a of jh exclude clearing of throat or a \ single cough. 9 9g ! b. How long have you had this particular condition? b. | 1 [7] Less than | year | i 2 [7] 1-3 years y 3 [7] 4-9 years | 4 [7110 years or more | 9 [7] Don’t know ! = c. Do you have chest pains when you have ei 1 [7] Yes — Ask d morning coughing spells? | oF No | 2 []No-— toe d. Wher di Yes No Upper Baek «vive wwii v vin inin wv vans || GD i 2] | Vawerbackss ising ie wasn coveee | GB) $7 20) | | Upper ehashs sims eis vies sd vs cee 1 @) 10] 2] | Along the rib edge. . . . . . . . wal wld | On the tides. «.vvins mswmm cee 1 @) OO 2[ e. What time of year are these moming coughing el 1 [7] Winter i ? spells at their worst? ! 2 [] Summer | 3 [] No difference f. Do you have a morning cough like this on ti @ 1 [Yes most days for os much as THREE months i hu? each year? ! 2 [TJ No I g. Do you usually have a persistent cough at ge! - other times during the day or at night in the \ @) 1 [1] Yes winter? (IGNORE AN OCCASIONAL COUGH.) | 2 [No i h. Do you usually have a persistent cough at h.! other times during the day or at night in the : 1 [1] Yes © summer? (IGNORE AN OCCASIONAL COUGH.) | STING ‘ J : PHLEGM T 3a. Do you usually bring vp any phlsgm from your Ja.) 1 [C] Yes — Ask b chest first thing in the morning? (Count phelgm ! ’ a with the first smoke or on going out of doors. : 2 No S0P dy Exclude phlegm from the nose. Count i swallowed phlegm.) ; . ! 1 [7] Less than | year a [7] 10 years or more t _ | C = b. How long have you had this condition? ! 2 [] 1-3 years s [] Don't know | 3 [4-9 years i 35 36 c. What color is the phlegm? ci Yes No Green. ....... Son bit ly HE Sel l@ 0 2 [7] Yellow... .. FR RE YY 40 | 0 20] CVRBE: avanti wri cot ie iin 195033 eee LE YO 2 Blouitnionts susie Fue sspillarinn sins wisi : “ d. Da you also bring up any phlegm from your chest d. | at other times during the day or at night, in the | 1d Yes winter? (At least two times or more) ¥ 2 [No e. Do you also bring up any phlegm from your chest e. during the day, or at night, in the summer? 1 Css (At least two times or more) i 2 [No i | f. What time of year do you seem to bring up the f.! 1 [7] Winter most phlegm from your chest? | 2 [7] Summer i 3 [] No difference 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 CJ Ne each year? i - SHORTNESS OF BREATH | 17] Yes - Ask b 4a. Have you had shortness of breath either when 4a, 2 [1] No = SKIP to 5a hurrying on the level or walking up a slight hill? y b. Hove you had this problem most days for as much b.. (13) os THREE months each year? ! @ ¢. Do you get short of breath when walking with «' other people at an ordinary pace on the level? ! d. Do you have to stop for breath when walking 4} at your own pace on the level? | e. Do you have to stop for breath after walking about 100 yards or after a few minutes on the level? ’ f. How long ago did you first have this trouble f. 1 [7] Less than | year ago with shortness of breath? \ 2 [C] 1-3 years ago i y 3 —9 years ago ! 4 [110 years ago or more ! s [7] Don't know L g. Have you gotten chest pains along with the a! 1 [7] Yes — Ask h shortness of breath? ! 2 [No -SKIP toi h. Where? ht Yes No GER HES inion ae wi way messed wvsnsans 3 EBD 2 | Upper back... .. stir a SAA SR ORs 2] i Lower back . . . . . FE LEO 23 i Along the lower ribs ....... wnt mwa 1 Gay HEC 23 | On the sides. . . . . . oh se nan 3 (G0) 2] i. Do you develop wheezing as well as shortness $e 1 [7] Yes of breath? 1 2 No j- Have you ever felt like you were going to pass is (049) 1] Yes out from the shortness of breath? 2 0 No fi WHEEZING 5a. Hos your chest ever sounded wheezy or Sa. whistling? b. How long have you had this condition? b a . Do you get this wheezing or whistling with colds? d. Do you get this occasionally apart from colds? ~~ d. e. Does this usually occur daily? e. f. What time of year does it seem worst? + g. Is this wheeziness present on most days for as gq. much as THREE months each year? 1 [7] Yes — Ask b 2 [ ]No— SKIP to 6a 1 [7] Less than | year 2 [] 1-3 years 3 [7] 4-9 years 4 [7] 10 years or more 1] Yes 5] Animal COMOTts. viv wove vivian we aa DRGs suis vvviv swe rsvwmes Pollens. . Molds: wins viv uiniivn » iain Other — Specify Don'thnow wiv wimv svineman h. Do you take any medicines for wheezing? hol 1 [7] Yes - Aski i 277] No = SKIP to 6a i. Do they help relieve the wheezing? te 1 C] Not at all A small amount A great deal | ASTHMA ! Yes — Ask b a. Have you had, or do you now have asthma? 6a. No — SKIP to 7a b. What is it related to or due to? b. sg) [1 2[] eg jm 2[] Ju! 6c. How long have you had this condition? [7] Less than | year — SKIP to e [7] 1-3 years — SKIP to e ~ ! 3 [_] 4-9 years ago —SKIP to e | 4 [7] 10 years or more — Go to d i r d. Since you were a child? d! 1] Yes | 2 [CINo | e. Do you have asthma symptoms on most days for e.! 1 [T] Yes as much as THREE months each year? : — 2] No f. What time of year is it worst? fi Yes No SPRING «eevee @ 0 T 00 Summer ...cicinnennn win Tien win aie ale I tC} 2] | Fallooovnin @ vo 0 | . ! ~~ WARIS ori mismo oo a le Se RR i LED 103 20] . Do you take any medicines for it? | g. Doy y ol ClYes ! 2 [No BP HAYFEVER | 1 [7] Yes — Ask b 7a. Have you had, or do you now have, hayfever? a, 2 [| No = SKIP to 8 I b. What is it related to or due to? b.! Yes No DUBE a.1550m esi satin van wise, ous. oom Va 3 | @ +O 20 | Pood: 2 iaieu vive sinin iin sone ai dae ! i 2 oods | | 0 Arial contetsis. viviv 245s 5 tien 38. s NG) 10 2] | DIGS. sane sia secs BUTEA ER ! 0 200 Pollens. . .. .. i AHI LD) 10) 2] i Molds... wiwnseneis L @ 90 20) Air conditioners . ......... wanseiead EY 10 2] Other — Specify ! 0 2 Don't know. ...... IAAT wr s(] I How lang have you hud this condition? el 1 [7] Less than | year — SKIP 10 i 2 [7] 1-3 years —SKIP toe 3 []4-9 years — SKIP toe ' 4 [7] 10 years or more — Ask d L ’ d. Since you were a child? 4. [Cl Yes } 2 []No i 7e. Do you have hayfever symptoms on most days ~~ 7e. | 1 [J Yes for as much as THREE months each year? | = | 2 [No | f. What time of the year is it worst? Hd Yes No SEONG wanes am ans ase 5 5 TORY, % [ 2] | N RA A EA SR iC 2 ummer | 0 0 Fol wmanr so otf de ES BAN i 2[ a Oo 0 | 5 i. Winter | 2 2] 3. Do you take any medicines for it? % ' ves | 2 [No D> MEDICAL CARE ! 1 [7] Yes — Ask b 8a. Have you ever been tested for TB (tuberculosis)? 8a. | 2 1 No — SKIP to 9 l : b. How were you tested? i Yes No Askin tent u wate ss Sie Wis Enis a Re 4 vw 2] Chestaarays cai vas vn see sinh Sn dis ow wl) 2] SPUTUM eXaMINGHON + «vss es eueatnas 0 2] Don’ tknow .ovvvunninnnnnnrnnnnnes | s [J c. How often are you tested? e 1 [] Once every year ! 2 [] Once every two years 3 Once every 3-5 years 4 [] Less often than once every 5 years L d. How long ago were you last tested? & [7] Less than | year ago “J 1-2 years ago [13-5 years ago [7]6-9 years ago [7] 10 years ago or more I [] Don't know 9a. Have you seen a doctor or anyone else about the chest or lung conditions you mentioned previously? oo What is the name of the doctor you see? a What type of doctor is he? a . Who initially referred you to this doctor? 1 [] Yes — Ask b 2 TJ No — SKIP to 10 [] General Practitioner |] Internist [_] Osteopath [] Surgeon [1 Lung specialist [] Allergist 1 Other — Specify Noa sown = 1 [1 No one 2 [7] He's the regular doctor 3 [7] Another physician 4 [] Health nurse s [_] Clinic 6 [_] Family 7 [] Other — Specify 37 38 9e. How long after you first developed the problem 9e. did you see him? f. What did he say the condition or conditions f. ” affecting your chest were? eee Se eit TR ee eter ® 1 [_] 1-6 days 2 [] 1-7 weeks 3 [_] 2-6 months 4 [J] 7-11 months 5 [_] One year or more 9 [] Don't know DATA PREPARATION USE ONLY 0 0 @r 0 0 @ 0 0 @ 0 OO @ 0 When you see the doctor about your chest 9. condition, how often do you receive a chest x-ray? + Does he prescribe the medicine for h. the condition? How is the medicine taken? i Swallowed. ......00vviunnns cevarnan Breothed uu ivinsnnnvmnvinesivesinyine Injected oma wiv id winnie ei ae Other — Specify. Has he told you to do any of these other things |. for it? Breathing exercises: s va iv iv sores snares Use a breathing machine ............... Stop smoking... .... Care wae SE ee Decrease smoking +. vais vvivveivsviv conse RiEgular SHeakypin:sie savas slo wisn aida > Lots of rest «ou insvananvnmsmariimnns Decrease activity .....u000nn Ca aaaaiae Other — Specify. Geeeee a |] At every visit t every other visit Less often than every other visit © 1 [J Yes — Ask i 2 [No —SKIP to cma Yes No | | 3d 2] =| 2[] @ 0 2 Yes No @ 0 20) @ +0 2] | 2] @ 0 2] wm) 2] @ 0 =O oO 20 0 = feces ! k. When was the last time you saw him? | 1 [] Less than | month ago I 2 [[] 1-3 months ago J 3 [_] 4-6 months ago ! # []7—11 months ago ! s [7] 1 year ago or more ! s [7] Don’t know I. Where do you usually see him? Li @) 1] Achis office A 2 [] At a clinic } 3 [_] At home \ 4 [] Other — Specify L m. How long will it be until your next mi @) 1] Less than | month RpFiRw ; 2 [7 1-3 months ! 3 [] 4-6 months : 4 []7-11 months ! s [J 1 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 [7] Gotten better 3 stayed about the same? i I — i 11. Have you ever been disabled because of any ~~ 11. 1 (30) 1 [Yes chest condition? : 2 No ! rT T 12. Have you ever stayed ovemight in a hospital 12. 1 (13) | [ves because of a chest condition? ! | 2[1No 13. What was your job status one month before 13. | (38) 1 [7] Retired because of age re first had a problem with a chest or | Satred be il ung condition? ! 2 [] Retire cause of disability ! 3 [| Unemployed ! a [7] Working full-time ' s [_] Working part-time } 6 [_] Housewife with full duties ! 7 [] Housewife with partial or no duties } 8 [_] Other — Specify. | ? ! sy T 4a. As a result of your chest or lung condition, ~~ Mo.! (13) 1 [7] Yes — Ask b has there been a change in your job status? | 2 1No—SKIP to IS b. What is it now? b.| 1 [7] Retired because of disability | 2 [] Unemployed ! 3 [_] Working only part-time ! 4 [_] Changed to easier job 1 s [] Housewife with partial duties 6 [_] Housewife with no duties | 7 [_] Other — Specify. | 7 | i 15. How many work days would you estimate you 15. | 1 [7] None have lost during the past 12 months because i 2 [] 1-4 da \2 . ' ys of your chest or lung condition, excluding | colds or flu? i 3 [[]5-9 days | I i i | | 1 4 [710-14 days 5 [1] 15-19 days 6 []20-29 days 7 [] 30 days or more APPENDIX I[IN. SUPPLEMENT C 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 0.M.8. No. 68-R1184 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 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. or not? lo. Was the problem that of chest pains, chest la.| 1 [7] Yes — Ask b discomfort, pressure, or heaviness? | 2] No — SKIP to 2a | | b. How would you best describe this pain b.| or discomfort? | Yes No ! Heaviness vas vis vias vive HA ” eaviness | 1 2] Burning sensation. + «vv vusersensons a 0g 20 1 | Tehessmo smmi mista | GO $5 200 ! S1Obbing pain. + + sv verrnniasserrrerees) @ 1] 200 | | Pressures si vie sia civn is snare 3 GR) +2 20 | Sharp Poin. oe vvrnnnnn. ER EUA TTR OJ 20 | Shooting Pains «sv srunsss wil aren. J 10 20] ! | c. Have you had it more than THREE times? oh [J Yes 2[JNo d. Have you been bothered by this within the &! 1] Yes 2 No past 12 months? ! i e. How old were you when you first had it? e 1110 ~ 19 years old 4 [7] 40 — 49 years old i 2(]20 — 29 years old 5] 50 — 59 years old | 3[] 30 — 39 years old 6 [] 60 years old or older] f. Do you get it if you walk at an ordinar, fl 1] Yes N oo roy y i = 20Ne } 9. Do you get it if you walk uphill g.! 10] Yes — Ask h ? Li | 2 [7] No — SKIP to k Th. What do you do if you get it while walking? Th. : Yes | | See serve ti on A ARATE ce @ 00 20] 3 ! SlowvdaWin sawn an an vibes weirs Bamneni | 0 2] Continue at same pace. ..... SA ER 10 20 ! : Take medi : : 0 20 ' = i. If you do stop or slow down, is it relieved i 1 [J Relieved — Ask j : ! 2 [J Not relieved — SKIP to k ® . How soon? 1 [_] Less than 10 minutes 2 [] 10 minutes or more * When you get pain or discomfort, where ®@®® is it located? Yes No Upper middle chest . «ooo vvvvnnnnnnn 1d 2] Lower middle chest... vvvuuenneennnnns i 20 Loft side of chestive vos vue wan vain vin 10 20 Left arm . iain BR view vie 10 20 Right side of chest... vu... — 0 2] Other — Specify. 10 2] I. Do any of these things tend to bring it on? Yes No Excitement or emotion +. +... 10 2] SIODPING VEE on sins von wainsinis sinie » 10 20] Eating a heavy meal + + vv vvuunense 10 2] Coughing spells... ... s £68 WAH. bE 0 2] CRIA Wid iv v oer vase vias sissies Ch i 20 Exertion «ov v00unn winie wwrwiie: wow ae i 2 2a. Have you ever had severe pain across the 26.1 1) Yes — 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 [J One TA iis ' 2[J2-3 Wi 2? uF c. What was the date of your last attack? el Month Year d. What was the duration of the pain during &! 1 [130 — 59 minutes 5] 12 — 23 hours your last attack? ! 2[] | = 2 hours 6] 24 — 47 hours ¢ 3[] 3 - 5hours 7 [[] 2 days or more : a] 6 — Il hours 4 e. Did you see a doctor about this last attack? Ze. 17] Yes — Ask f i 2] No — SKIP to 3a f. What did he say it was? f. DATA PREPARATION USE ONLY 1 Le 10 0 us! 10) 10 39 40 3a. Do you get pain or discomfort in either leg 3a. while walking? ® 1 [7] Yes — Ask b 2[7] No — SKIP to 4a b. Do you also get this pain in your legs b.! 1] Yes while standing still? 1 - ! 2 [No \ c. In what parts of your leg do you feel | 1 [7] Lower part (calf) this pain? | ! 2 [_] Upper part (thigh) | 37] Both lower and upper parts d. Do you got he ain in your legs while d. i 1] Yes quiet or while sitting? i 2C]Ne e. Do you get it when you walk up « hill ! 1] Yes i ? in a hurry? | 20INe f. Do you get it when you walk at an fl 1] Yes ordinary pace on level ground? i 1 2[]No L 9. Does the pain in your legs come on after 9) 1] Yes you have taken a few steps? i ! 2[ No T h. Does the pain disappear while you are hoi 17] Yes still walking? | 20] No i. What do you do when you get it while i] you are walking? i Yes No | Stop. «vive tereneaena i ® 4 2] | I PIL 20 | Continue ot some pace. «+ +vvvvensenenes | ©) 10] 2:00 | Toke mudicing + vx. vivce iviw mine ine isch in 00 LEH 10) 2] | 1 i. If you stop, is it relieved or not? i i 1] Relieved — Ask k | 2] Not relieved — SKIP to | i k. How soon after stopping? ket 1 [] Less than 10 minutes ! 2 [] 10 minutes or more I. Is the pain more likely to occur when you . 1] Yes are hurrying than when you are walking | = at a slower, more even pace? : 2[No ~ 4a. Have you ever seen a doctor about chest pains, 4a. T 107] Yes — Ask b chest discomfort, pains in the legs while = walking, or heart failure? 2[JNo—-SKIP to 5 b. What is the name of the doctor? & What type of doctor is he? 1 [7] General practitioner 5 [] Other — Specify ! 2 = iin AL | 3 eart specialist iy ] 4 [7] Other specialist 9 [7] Don’t know d. Who initially referred you to this doctor? &! Yes No No one eras TE 0 | @ 0 2] i He's the regular doctor +. vveseunseenunns i 10 20 Another doctor . . . . . . LE) 0 2] | Family sv vein seins ee ©) OO) 20 | Clinies + ess vevnssns wise wns sing wu wwe | IQEY 40) 2] I Health nurse +. ooveveniennenenenenes | @) 10] 2] | Other Specify i 10 2] | e. How long after this trouble first started did a 1[] Less than | day s[]| — 5 months you first visit your doctor about it? | 2] - 2days 6[]6— 11 months ! 3[]3- 6days 7 [J | year or more a[]1 — 3weeks 5[]Don't remember f. At that time, what did he say the problem was? g. Did you have a cardiogram af the first visit? g. 1] Yes 2[ No h. Did you have one at a later visit? h. 1] Yes — Ask i } 2[JNo — SKIP to 4j nd i. How long was it from the time of the % V1 - 2days $16 II months first visit? } 2[]3- 6days 6] | year or more } 3[]1 — 3 weeks 9 [] Don't know i k. Did you have one at a later visit? k. I. How long was it from the time of the I. 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. .. oun Perera Under the tongue ov vive suivemmwnmnines cen Injected ...00uu ine ee ee .“ Did you have a chest X-ray at the first visit? ie Other — Specify o a[] | — 5 months 107] Yes = 2[INo Q. ® 17] Yes — Ask | Cc 2[7] No = SKIP to m ® ® 11 — 2 days s[]6 — |1' months 2[]3- 6 days 6 [_] | year or more 3[]1 — 3 weeks 9 [[] Don’t know a[ 7]! — 5 months 1] Yes 2[CINo ®@® Yes No a 2] 0 23] 20d 0 23 4p. Has he told you to do any of these other things? Make regular visits «ovine iinrennn Have regular cardiograms « «++ «++. vs... Decrense aetiviy's vos vonavnsinn sive sins dncrease activity: «vv evri iin nnn RES vue tne vine since wine wun sini vials sikie v Do exercises... 1... Cesarean S10 SMOKING + + «vs vue uneateaneanns Other — Specify q. When was the last time you saw him? r. Where do you usually see him? 4p. | Yes No P@ 0 2] 1@® 0 0] | } 0 2] ! P@ Oo 20 F@® 0 20 I | @ 0 20 | 0 2] | L@® iO 20 1 [] Less than | month ago 2[) | — 3 months ago 3[]4~— 6 months ago 4[]7 — Il months ago s[_] | year ago or more 9 [] Don't remember ® 1 [7] At his office 2 [J Ata clinic 3[_] At home 4] Other — Specify + How long will it be until your next visit? ® 1] Less than | month 2[]1 — 3 months 3[]4— 6 months 4[]7 — 11 months s [1 year or more 9 [_] Don’t know of your heart condition? t. Would you say that the treatments you have t 1 [7] No, not at all had have done you any good? 2[] Yes. partly 3[] Yes, quite a bit Within the past 12 months, would you say that 5. 1 [7] Gotten worse your condition has gotten worse, gotten better, 27] Gotten better or stayed about the same? vn 3 [| Stayed about the same Have you ever been disabled because of chest 6. 17] Yes pain, leg pain, or heart failure? 20] Ne 7. Have you ever stayed overnight in a hospital 7 10] Yes because of chest pain, leg pain, or heart 2[No failure? 8. What was your job status ane month before you 8. | 1 [] Retired because of age first developed chest pain, leg pain, or i isabi Toor? barton 2 [_] Retired because of disability | oJ Unenployey } ! 4] Working full-time i s [_] Working part-time ! 6 [] Housewife with full duties 7 [_] Housewife with partial or no duties 8 [_] Other — Specify. | | 9a. As a result of your condition, has there been 9a. | 17] Yes — Ask b a change in your job status? 2] No = SKIP to 10 b. What is it now? bo 1 [] Retired because of disability 2[_] Unemployed 3 [_] Working only part-time 4 [] Changed to easier job 5 [] Housewife with partial duties 6 [_] Housewife with no duties 7 [[] Other — Specify 10. Mow many work days would you estimate you 10. 1] None have lost during the past 12 months because 20] | — 4days 3] 5- 9days a[]10 — 14 days s[]15— 19 days 6 []20 — 29 days 77130 days or more 41 APPENDIX 110. EXAMINATION FORMS (ALL EXAMINEES) Form Approved HSH-425-18 (pace 0.M.B. No. 68-R 1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY UBLIC HEALTH SERVICE All information which would permit WeaL Ty ERVICES AND MENTAL HERA omer aTion identification of ‘the ‘individual wil e held strictly confidential, will be HEALTH AND NUTRITION EXAMINATION SURVEY used only by persons engaged in 1 and for the purposes of the survey, and will not be disclosed or released CONTROL RECORD to others for any other purposes (22 FR 1687). a. Name (Last, first, middle) b. Deck No. c. Sex ¥ 2 1 [J Male 1 2[] Female d. Date of birth e. Age f. Examination date g. Temperature Month Day Year Month Day Year TIME Procedure or part of overall PROCEDURE oT STAFF procedure not done IN out (Enter reason for non-completion) 1. Casual specimen xd 2. Body measurements %iTy ® 3. Physician's examination x] 4. Venipuncture xi 5. Dental examination x] 6. Dermatology examination xd ® 7. Ophthalmology | x] ® 8. Ophthalmology II x] pe = « Nutrition questionnaire goss i 1 7] In home 2 [_] Not in home 10. Hand and wrist X-ray (Ages 1-17) x OFFICE USE ONLY Time in Time out Sample Number @) vO @) ~O @) np This control record is used for those examinees receiving only the nutrition component. The form repro- duced on page 64 is used for examinees receiving the detailed component. Form Approved HIS maou 0.M.B. No. 68-RI184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit AT TONAL CENTER FOR HEALTH STATISTICS To identification of the individual will HEALTH AND NUTRITION EXAMINATION SURVEY be helg sirictly Sonrisentials will be and for the purposes of the survey, GENERAL MEDICAL EXAMINATION — AGES 1-74 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. Pulse d. Blood pressure (over 6 yearsj svsToLic oiAsTOLIC Bz |@_ _ | ® @ _ I i i . Ngan aviv EARS, NOSE, | 1 [7] Findings| 4. CARDIOVASCULAR EVALUATION: | G8) [1] Findings i 7 : i : 2[]No If findings, mark applicable | 2] No If findings, mark applicable | findings box and continue with a. | findings box and continue with a. | If no findings, SKIP 5 / If no findings, SKIP to 2a. ; Yes ” % ! | | Yes | i a. Dry, staring hair... ....... I 1d b. Dyspigmented hair ........ | + | c. Easily pluckable hair. ...... J 10d d. Abnormal texture or loss of curl | 10 i e. Circumcorneal injection . . . . . : 1d i £. Conjunctival injection . ..... | J i | g. Angular blepharitis . . ...... | 10 hy Xerosis vues Pr ' “CJ To: BIGL'S SPOISLL » « viinis is winwie ! 10 j« Keratomalacia ..........n | Cy k. Xerophthalmia ........... ] 1d I. Angular lesions of lips. ..... ! 10 m. Angular scars of lips. ...... | 1 ” ’ |@ Oo ny Chellosis wiva « v viwivn « suis A 10 o. Filiform papillary atrophy | f tongue. & ¢ sive 2 viaies of tongue ! 10 p. Fungiform papillary hyper- ! trophy of tongue . .. .... ! 10 q. Geographic tongue ........ ! 10 8. CyanosiS.cviriinnanaan 4 4d): 3 b. Irregular pulse. «vou oun wi | @)1 7 c. Cardiac murmur . «oven | ©) Od (Describe: grade, location, radiation, probable valve involved, etc.) d. Other findings — Describe, 0 i 1 r. Fissures of tongue ........ ! 10 | . Serrations or swelling of tongue 1 os ortonpe | @) +O 1. Scarlet beefy tongue ....... ! 10 | u. Magenta tongue +. ue ue enn ; J v. Naso-labial seborrhea . ..... | J w. Visible enlarged parotids . . .. | [J x, Bossing of skull. « vvu uno nn | 1d y. Other — Specify 0 2a. THYROID EVALUATION: (WHO Classification) | | I i | | ! 1[] Group 0 ! 2[] Group | i 3] Group 2 | ! 4[] Group 3 i | | | ¥ | I | b. OTHER THYROID FINDINGS: 1 [] Findings 2] No findings (GO TO3) R L Both Tenderness . ..u vu ves | 102s] Nodule «sv + vse swsvs | @3) 1720030] | bsthmuss ss wos nw ens J 10 Other — Describe @) 0 5 box and contin If no findings, . IY ssssnnvnnas a. Hepatomegaly ! 10 | b. Splenomegaly + vv vv ven. 1 | « Uteri | tevennnn c. Uterine enlargemen | 10d d. Umbilical hernia. ........ | 10 e. Pot belly... f. Mass (es) .. I 1. Area(s)— | | 2. Other findings — Describe | 1 er finding: pi i 18} | | g. Surgical scars ... 1. Area(s) — 2. Other findings — Describe ” ABDOMINAL EVALUATION: If findings, mark applicable 1 [] Findings] 2] No ue with a. findings SKIP to 6. Enter number(s) Enter number(s) 3. CHEST EVALUATION: 1 [_]Findings I I | | | | | If findings, mark applicable H 2[]No i i | I I I I I | All persons 25 y ears old or older I : | box and continue with a. findings 7 0 | If no findings, SKIP to 4. bi diyarsine | Yes TIGL + szeion.s Zev Ge) _ mm. a. Beading of ribs. ...... sk 1 2. MSL ! mm. MBL & «vans wae es te b. Follicular hyperkeratosis | d of upper back ......... 1 po : 2 yon c. Wheezing on auscultation 1, Diffuse soiviis v oioivn v ! 1d 2. FOeBl, « voviw v vuwwsn » | 10 d. Decreased breath sounds (diffuse) = veiw voces ! 10 e. Other findings — Describe I | I | | 1 1 | 1 L Sample Number Sample Number 43 44 6. MUSCULOSKELETAL EVALUATION: If findings, mark applicable box and continue with a. If no findings, SKIP to 7. a. Bowed legs «.avvvv ven b. Rnock knees... vox svunss c. Epiphysial enlargement, WHSES ...c0vnnnnnn d. Other findings — Describe 1[] Findings ! 2[]No | findings y Yes I 108) 1 ym L@ 1 @9 +O 9. GENERAL EVALUATION: (Conditions which might affect normal growth and development or affect the evaluation of nutrition, such as mongolism, cerebral palsy, dwarfism, parental neglect indicators, etc.) If findings, describe below. If no findings, SKIP to 10. @) 2 Findings No findings 7. NEUROLOGICAL EVALUATION: If findings, mark applicable box and continue with a. If no findings, SKIP to 8. a. Absent knee jerks . ..... b. Absent ankle jerks. . ..... c. Positive Chvostek sign ... QaAPAIY # + » 5 3a 0 ¥ 3 winisie e. Marked hyperirritability ... £. Other findings —Describe — 1 [] Findings No findings Yes © 1 @C @ 0 LED) @ 0 @ 0 10. SUMMARY OF FINDINGS: a. Nofindings ......c00vennnn b. Findings relating to nutrition «.. ocean cess (List findings) @) @ 0 c. Other findings, NOT relating 1 1 } tONULFILION + vv enn ven nenn ' : (List findings) ) i 1 | i ; = 8. SKIN EVALUATION: | @3) 1+ [Findings | 5, If findings, mark applicable | 2] No ! box and continue with a. i findings 1 Se st If no findings, SKIP to 9. ! 3 ! . 1 a. Follicular hyperkeratosis, arms | + J b. Hy perpigmentation, hands | | TT andface ....covuens d 1d 4. ! v " ! | a c. Dry or scaling skin ...... y 1" 11. EXAMINER'S SUBJECTIVE ifolli i ’ IMPRESSION OF NUTRITIONA| d. Perifolliculosis ........ | 8 | STATUS: | | e. Petechiae — Describe | + | = ' a. Normal nutrition ............ | +] | 1 ! b. Abnormal nutrition. .......... ! 2) f. Mosaic skin, . « common ss : i] | I g. Pellagrous dermatitis. . . . . L@) 0 12: DUET wai 9 maemns «sme LO : 1 bh. Ecchymoses — Describe, J No obesity «oyu vwwins se yawy ! 2] i. Other findings — Describe, @) +O 13. Name of physician Sample Number HSM-425-7B (race 1 Form Approved \ 0. REN M.B. No. 68-R1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE rr ree ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE * + HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION Il information which would permit NATIONAL CENTER FOR HEALTH STATISTICS identification of the individual will HEALTH AND NUTRITION EXAMINATION SURVEY be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, 1 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. m oo Measurement in cm. unless otherwise specified. NOTE Measure left side also if the last digit of examinee’s sample number is 3 or 6. 3[_] Uses both hands about the same a[_] Not sure 8 [|] Not applicable 9. Weight (Ibs.) 9. 1. Bitrochanteric breadth 1. | ' ie is } RIGHT SIDE LEFT SIDE 2. Elbow breadth 2.1 (0) meine fetid omg) ged v Rion Soe TerT Soe 3. Upper arm girth .@) @) _ Head and chest circumference (I—7 years) ! 4a. Head 4a.| ok hs 1 | b. Chest b, @2 a y RIGHT SIDE LEFT SIDE 5. Triceps skinfold ( mm.) 5. ! I = S— 1 | RIGHT SIDE LEFT SIDE 6. Subscapular skinfold ( mm.) 6. | a a TIE SEES. faa I | 7. Sitting height 7: ! hs Fo T When both sides are measured: | 1 [_] Right handed 8. Is examinee right or left handed? Ss. 2[] Left handed I 1 1 i 1 1 l | I 1 | T 1 I 10a. Standing height (cm.) 100.) WY nn is ie b. Standing height (inches) Sample Number 1 The form shown here is for use on nutrition examinees. The form for detailed examinees is identical except for omission of item 4 which is replaced by chest circumference - full inspiration and full expiration. HEALTH AND NUTRITION EXAMINATION SURVEY peck Ne. . 15k DERMATOLOGY EXAMINATION (USE RED PENCIL TO FILL FORM) NAME (Last, First, Middle) SAMPLE NUMBER EXAMINER NO. STATE OR FOREIGN COUNTRY OF LONGEST RESIDENCE _—] —— mn. Years OCCUPATIONAL EXPOSURE 003 100 Yes 2] No EXPOSURE TO LIGHT by hist IF YES: (CHECK ALL THAT APPLY) Gy history) %] 1[C] Chemicals, fumes, or vapors 10 Immersion (hands or feet) 1] Unimpressive [8 13 oils 1[C] Other (SPECIFY) 2[] Moderate [O08] 10 Insecticides 3] considerable FINDINGS RELATING TO NUTRITION SIGNIFICANT DERMATOLOGICAL DIAGNOSIS MADE PREVIOUSLY PHOTOGRAPHY OF SKIN: Frame No. NOW SUPPRESSED OR IN REMISSION Lesion diagnosis code Code Certain Probable Doubt ful 1. meme} 1] 20) 30] za 2 I 10 20 30 GENERAL APPEARANCE (1 - 3) [M25] Age at first “3. Skin Texture 1. Hpir color (Natural) graying_ _ years | [O30 Surface 1] NO FINDINGS (CHECK 1 BOX) [_] Coarse 2 Fine Previous Hair om) ICT76iTy 3[7] Scaling ~"3(C1 Both _ 01] Gray 1, 2 Color if Gray fo) 10] Moist 7 "7" TTTTTC SERRATE 02] Gray 3, 4 or White [El pry 1[] Senile 2] winter 03] white 3] Both 4] Atopic Dry 04) Black _ _ _ _ _ _ _ _ 057 park brown_ _ _ _ _ I A i 060] Medium to Tight brown _ _ _ _ _ __ (1) arrophie 20) Thtobune i 07C] chestnut or auburn_ _ [038] "1[] “Other (SPECIFY), 08] Red (titian, carrot, etc.) _ 09[_] Dark blonde Complexion CHECK 'YES OR 'NO'" FOR EACH ole Skin Color ed, tinted or bleached? M27] 1] Yes ets i ig ie cere vemcaa 200] No Abdomen [0391 Sr it Flag signs? AT i Yes” 7 1 Forearm [0401 ; —al te Hy im) OT 2, e Color - (CHECK 1 BOX) 307 Tryshamerces 1] Dark brown 5) park blue 2[7 sallow 2[J right brown 6) Light blue 300 Gray,green, 7[] Mismatch hazel 81 Other (SPECIFY) 4 speckled Nevus of Iris — (CHECK 1 BOX) * 137 Right « 2(] Left 3[3 Both 4. PIGMENT ABERRATIONS ill Items 4-6 —> [043] 1(C] NO FINDINGS (GO TO ITEM 7) iype Impression hyper... [E51 10] Melanin generalzhype ________.__._.._.._ ©5710] Addison!s disease 177] Melanin general-cosmetically disfiguring] [058] 1[] Albinism - Total a i 2] Albinism - Partial Melanin localized [047] Face (028) Body il] Vitiligo - Total a Extremities [] vitiligo - Partial (050) oe’ [C1 Chronically i (063) ] Other (SPECIFY) (053) IC. senile depigmentation _ __ __ _ | Surgi- | Therbie 1 Icterus ot! (oss) IC] rEifact (08%) [O58 1 Tatoo - traumatic [085] 20 Tatoo - traumatic - cosmetically disfig. [6s] NEVI (Clinical Junctional Hutchinsons fr.__ Mong. spot Blue nevus Nevus of Ota Vasculosus Cavernous Senile ITEMS 1-10—>[IT] 17] No FINDINGS (GO_TO_ITEM.11 VASCULAR CHANGES OTHER THAN NEVI (7 - 10) 7.77" RAYNAUD'S” PHENOMENON CTT TT8 VASCULAR CRANGES OTHER TRAN NEUITTTTTTTTTTTTTTUUC Source (CHECK ONE) Lecation (CHECK ONE) 15] 13 purpura-senile [II7] 1[J Coldness IZ) 1CJ observed I& 11 vands Other purpura (CHECK ONE) (118) 1[.] Cyanosis 20) By history 20] Feet O16) 1] Traumatic i o 30 Both 300 Both 2[] Med. induced dema, chronic Duration 3] pis. related (O0Z0) 1CJ Persistent Or __ __ years 4[C] Idiopathic 2 Recurrent SC] Etiology obscure [IZI) I[J Cutis marmorata 9. ACTINIC DAMAGE —> 10. OTHER TELANGIECTASIA 1. MISCELLANEOUS LESIONS OF COLOR AND TEXTURE 1] NO FINDINGS (GO TO Many ITEM 12) Fo I Legation Clavus (feet) == Se 100 23 (028) 1[J Face [029 1[J] Extremities Seborrheic keratoses i 2[] Scalp and neck 2[) Trunk Face and scalp Mei] 10 27 3[C] Face, scalp, 3] Trunk and Back and chest 162] 10] 2] and neck extremities Nasolabial or other | body folds 143 Tl. Impression Papulosa’ nigra L44 2] 1[C] Weber Osler Rondou [IT3) 1[C] Idiopathic Epithelial tags 145 2 1[C] Post irradiation familial Neurofibromata 46 2 (032) 100 Sclerodactyly [13] 1 Poikiloderma ibromata 47 a vasculare Epidermal nevi 48 2 atrophicans Warts-hands 49 areal O35) 1] other (SPECI- Warts-feet 50 2 FY) Warts-genital 51 2 Warts-other (SPECIFY), 52 : | oe Tophi. 53] vim Family history " 54 md [36] 10] Mother ~~ 2[J Father 3] Both Acantlivels nigracane 33 2 CIID 10) Paternal 2[] Paternal 3(J Both Lichen striatus 561 2 male female (138) 10] Maternal 2[C] Maternal 3[] Both male female 12. NEOPLASTIC CHANGE ED 1[C] No FINDINGS (GO TO ITEM 13) I | ' ! ! Benign Size of largest ! (1f£>9, codeto 9) | Lipoma__ ___ cm. | Ganglioma_.. [THY] em. | Sebaceous ademoma___ [HZ] cm. Lymphoma, leukemia_ _ Benign neo- Er — Metastatic _ _ | plasm of | sweat glands | and ducts___ | Other fibro- | mata. _ _ _. (IEE) cm, ECTODERMAL APPENDAGES 13. Ectodermal glands —— (I¥7] 1 Eccrine Apocrine (post pubertal Mammary gland developmen Fox Fordyce disease 1] Absent B8(] Marked O3511[0] Axillary (37) 1] Genital 2[] Deficient [(9611[1 Para-areolar Sebaceous glands; Sebum production [I98] 1 [7] Increased _ _ Ce Inclusion cysts (no 199] 1 [1 °L74 CITE Largest Zoo cm. (9 or A, code to 9) Location of cysts :——=> [2 1) Chest (Z07) 1] Face G03 100 meek 200) 15] Other (SPECIFY meee 14. NAILS —-——> (205) 1(] NO FINDINGS (GO TO ITEM 15) Fingernails (TOTAL NUMBER) (ZOE) __ _ Abnormalities (RECORD NUMBER OF NAILS INVOLVED. IF LESS THAN TEN PRECEDE NUMBER WITH 0) Color Z07]___ ___ white; [Z08) __ ___ yellow; [209)___ ___ Green, brown or black Quality C0) soft; XD __ __ Brittle Contour ZIZ)__ __ Raised; 2I3) ___ __ Spooned Sur face ZIZ__ __ Ridged; CZI5] __ __ Pitted Other ___ Thickened; [2X7] ___ Clubbed Complete absence of nails, mot traumatic [218] 10) Bands [(ZI%]___ __ White,cross;[220] __ __ Pigmented long Clinical impression of abnormalities noted above: [ZZ1] 1[J Fungus 2272] 1 Trauma [(2Z3 1 Alopecia areata [224] 1] Lichen planus [225] 1[C] Nevus [226] 1] Psoriasis CZZ71 1] other (SPECIFY), Toenails Abnormalities 1] Thickened (229) 1[C) Dpiscolored [230] 1(J Pigmented bands Clinical impression of abnormalities noted above: [230 1] Fungus (232) 10 Psoriasis (233) 1[J] Nevus [Z3] 10 Trauma 1[J other (SPECIFY) 47 48 13. HAIR —> [236] 1] NO FINDINGS Scalp: Pattern Localized Diffuse Impression zo 10 zz) 10 Zz 10) Texture: [2%6) 1CIrine 20] Coarse [ZZ7) 1Chory staring 2[7] Easily plucked 3] Eyebrous: [228] 1[Sparse 2(] Absent Eyelashes: 1[CIsparse 2[] Absent Facial Hair (post pubertal) Males [Z50) 1[TISparse 2[T] Absent Females [251] 1 kxcessive Axillary 1[Jsparse 2[] Absent Pubic 1{TIsparse 2(C) Absent (not shaved) Body Hair Anterior Thorax__ Posterior Thorax_ Arms z= 10 3%) 10 256 100 Zea 10) of etiology Areata [ZZ1)" 1 Infection Anti meta- [243] 1] Trauma bolites Postcli=- [245] 1(C] Familial macteric Both Alopecia [233] 1] Genetically Areata determined Post infec- [255] 1(C) Post trauma tion Endocrine (257) 1[C] Other (SPECI- FY Inappropriate escutcheon REGIONAL EXAMINATION 16. HEAD AND NECK [28] 1[CJ No FINDINGS (GO TO ITEM 17) Scalp 267) 100s 10] s caling 207) Erythema 3[7] Both Impressions: 1[CJ] Seborrheic dermatities 1[J Trauma 1[J) Psoriasis 1) other Eyes Ever Age Family History bservation Noticed? of onset arents | Sibs | Both es No Yanthelasma__ _ [7a iEd 2073 — — p74 100 20 [33 Arcus senilis__[275[[1C] 2(_][276] p77 11 BIE Blepharitis (angular)_ _ _ [27811 2(21f779) 80] 1] 203 | 303 Blepharitis (not angular)__|781)|1[] 287 8 20] =| Hordeolum_ __ [284] fess] [lee] 1) C30) Chalazion_ __ _ [287] 288] 289 1] Pterygium _ _ _ |290]101 2L_1f291] 29 Tumor_ 1293] 294] 29 Ears Deformed [236] 1[0) Acquired 2[] Congenital [237] 10] Chondodermatitis helicis nodularis Nose Deformed 1[0 Acquired 2[C] Congenital (saddle, etc.) Mouth Buccal] Observation Lips Mucos: titel Tongue Fissuring R99] 11300 1(7] 307] 1) [B67]| 1] Pigmented Tes. _ [303 30 305 06] 1] Leukoplakia_ 7 30 304 1] [p10 Lichen Planu: 1 312 101] 131 14 Tumor 5! 316 314 10 B18 Angular les. or scars p19] 100 Cheilosis 32010] 18. TYIGHS AND BUTTOCKS [339) 1[J NO FINDINGS (GO TO ITEM 19) (30) 1 Venous stars (F&I) [7] Pilonidal cysts-dimple 2[] Pilonidal cysts-drainage 3[C) Pilonidal cysts-no drainage (322) 1[ZJ Rectal fistula (33) [J Inter-glateal Fissure ~~ 7° 19. GENITALIA (34 i) 1 NO FINDINGS (GO TO ITEM 20) 1 Chancre [Redness and scaling due to: 2[] other VD 1] Posriasis 3) Both 2[Jseborrheic derma- ELS ins [38] 1[C] Ulcers iJ Candida” "77" 2[] Parasites 3 Both 20. EXTREMITIES 4[] Uncertain T3%9] 1[C] NO FINDINGS (GO TO ITEM 21) everity Disfiguring Clubbing acquired iy Mod. [Severe || Yes [No 0] familial 1ie | ar) 10) 207 Clubbing] [332] O23 Wr zed oad 101] 200 Deformity acquired 1 0a) 1120) De formi ty; familial 1 oar) 10) 20) Follicular hyper No color |Peri-foll. is change | redness Upper -outer arm_ B6oi] 1) 2) Tongue (cont'd.) General macroglossia Rest of upper extres 361]] 1[7] 2] Mal developed generally : Bell 1 2 107 Forked CIZZ) 107 Partial atrophy 20JFull atrophy | Corire &rm 0 - Papillae Upper-outer legs B63] 10] 200) (323) 1 Atrophic [32%] 10 Geographic 3[] Pyramidal ROSE OF TONE ERTom. 10 20 2[] Black hairy 4 scrotal === Palate Entire leg 3651] 1] Fi [3251 10) Smokers 2[jGlandular hypertrophy [326] 1[] Arched br 2 (non-smokers) 3 cleft Upper back — —- .— ._.. [66] 100 0 Color 33 Both Abdomen _ __ _ . _ _ 367} 100 23 1] Beefy red 2[7] Magenta Buttocks _ Ss UT) on Other findings: [328] 1] Serrations 2(2) swelling(marginal 3[_] Both (marginal bilateral) bilateral) 17. THORAX AND ABDOMEN —— [329] 1[] NO FINDINGS (GO TO ITEM 18) Supernumerary areolae: [330] number with glandular tissue 31] number without glandular tissue Gynecomastiai . o.oo... 332) 1 Minimal Etiology 2[JMarked 3] 1] Medication 20] Liver dysfunction 3[C] Both SEriae: aioe. 0338) 1C]) purple [335] 12] white C736) 1 Pigmented 37 1 Draining fistulae or other lesions 33) 1) congenital malformations DISEASE ORIENTED EXAMINATION [369] 1[ ] NO DISEASE [ (ITEMS 21-31) SKIP TO EVALUATION ON NEXT PAGE-] 21. ACNE VULGARIS cm 1) Inactive 2[7J Active A Extent of acne 26 cont'd) Cause of Urticaria (CHECK ALL THAT APPLY) [Severd | (G08) ICT Food ~~ [409] 1[) Inhalant ress [@1) 1[] Obscure or other (SPECIFY), 27. [&I%4] 1] Medication 416) 1(C) Chemical CONTACT DERMATITIS (CHECK ALL THAT APPLY) 1] Plant (Z13] 1[C] Rubber [ZI5] 10) Leather [Z17) 10) Cosmetics Om 1 370 103 chest (218) 1] Metal [219] 1[J Obscure 1 1[7] Fabrics 378) 3 a 28. FUNGAL INFECTIONS Impression KOH Wood's Lamp site Yes | No |Pos. Pos. | Neg. |N.D 22 gi ACNE (CHECK ONE) Rev] “ ig Seried 30 froastory preparajscalp 1 2000) 1 200s 401 oil Feet 1 20] 10 2000 ACNE ROSACEA 1527) [228] 29] 379 10) Minimal 3(J severe Hands aC) 200] 3 10) (20000 2 Moderate T CLL DERMATITIS (CHECK ALL Rodin orotn, a | 0holobo | an obo EY CED 10] Eyebrows ___ Vther { Ez 10] a 83) i= Post _auricullyy 0 | ahitlalbo : »01ls0 38a) Ep-E os 10] Culture taken for Fungi Culture taken for Candida? BD 100 ves 2 No 24. PSORIASIS : hands: (388) 1] Inactive Min, | Mod, | Severe] ¥ 2 2[J Active BES] CJ] 2001 3L] 8) 10] Groin [C1 Glabrous skin Location [2201 112] "Body 390 1[J Trunk 29. VIRAL INFECTIONS (EXCEPT WARTS) 1] Scalp only 2[C] Extremities only 2(Z] seborrheic 3[] Both areas only 3[7] Both Joint Involved Viral Vesicles: Diagnostic Impression 1C] H. Simplex 3(C] M. Contagiosum 2[C] H. Zoster Tzanck smear 17] Positive 2[] Negative 3[] Not done 4[7] Primary Varicella Family History 1) Parent 2[7] sibs N 1 relatives ~ Did joint problem precede psoriasis? Yes 2] No 25. ATOPIC DERMATITIS Severity 100 Minimal 2[] Moderate 3[C] Severe Distribution 9] 1[C] Flexural areas only 2[C] Flexural areas and other (SPECIFY) 3[] Generalized Family History [&00) 1[] Atopy _ Eon 107 ured Personal History 1[0) Urticaria and/or asthma 26. URTICARIA (CHECK ALL THAT APPLY) GZ (705) 1] Giant 1TJordina [ZB] 1[J Pediculosis pubis [Z83] 10] Pediculosis corporis [4B4] 1[CJLeishmaniasis 30. BACTERIAL INFECTIONS 1 Description/Severity |Scalp| Face | Trunk| Ext Cult? Furuncles 3) [444] | B45) G46] Min. [J 1 130 Nh 1 rd Mod. 2 2 2 2 2 1 Yes severe [3] 3 3 3 3 Folliculitis 51) 25%) Min, 1 sili 1k] Lo) Ee Mod. [PCI ]2 10 ves Severe [3] 3| Impetigo 759) | GED) Min. 1h 1] 1k 1 Mod. 2 2 2 2 1[C1Yes Severe 3 3 3 3 TBC [G61] [266] mn, jC Lie] 11 Mod. [2 2 2? 100ves Severe [3 3 3 Hansen's 267) [468] | [469] (E70) zm Disease Min, RE IBY. 1 10] ee Mod. [2 2 2 2 2 1] ves Severe [3] 3 ri 3 Swim. Pool %z81 Gran. Min. L 1 1 10] 1 Mod. [2 2 2 2 2 1] Yes Severe {3| 3 3 3 3 31. ARTHROPOD AND PROTOZOAN INFECTIONS 1[T] Pediculosis capitis [4B0) 1[CJSwimmer's itch [282] 1[CIMites eeping eruption 49 EVALUATION OF DERMATOLOGICAL COMPLAINT [ZBE) 1] NO CONDITIONS (END OF EXAM) LOCATION . SEVERITY OTHER (SPECIFY EVALUATION HAND FOOT LOCATION EVALUATION ONE MIN. MOD. SEVERE — mm [me Ga rv jas 32. Diagnostic Code Recurrent? [Ta 37. Disfigurement 1 [1] Yes 1 Clves| 1 [J] ved (examiner eval.) 2 [1] No 2 [No 2 [No 522) IF YES-Months bh 233) Bend : 2 AT 140] sstive in past 12 Foot EZR 120 1a) aC) [ze] @7 TZ98] [TOTAL Other alr lem am Ha ISKIN Years duration on —— |cOMPLAINT [38. Discomfort (Patient evaluation ) en Ee | ; Percent limitation a. Pain or of activity Burning- Hand GEE) fe] 1303 af] 33. Handicap to Gain- ful Employment or Foot Zen] 1207 [30 [4 Housework Go | Total 1] I) 1c 1[7) Other Zand fz 1303 («0 Part-severe _____ [2 2(3J 20 h[O Yo tein Part-minimal, ___|3 30 300 1 : Z8 None 4 4 4] 4] Mant a 20) 1500 140] Precludes prefe T5081" "1 "IsoeI ~TRIeT TT Foot GE 200 [33 «Od occupation 1 Yes 1] Yes 1 Yes t1[] Yes 3. Handicap to Social other [SSOML] T2070 130] Js[] Relations il) ET c. Limitation of Motion- severe ______ [CJ 10] i] hi Lo Minimal __ ok 21) 207 2 Hand GOT 200 [30] [a4] erie 3 =i] A110] root GENO oC] la] |e 35. Care Sought({CHECK Ee Other Gen 1200 [303 [40 5316] a Non professional. [L 1 1 4 guerall 5191 ARERR Pherraey E rbd Hand cho) [200 3 40 : 10] ¥.0 Ls Foot sho [200 | «0 Podiatrist _____ [1 1 a) Other Gem 1200 1307] 1403 Osteopath. _.__._. a) 10] 10 idl] E31 532 B9. OBSTACLE TO IMPROVEMENT OF CONDITION (CHECK ALL Dermatologist... [1] i 1) THAT APPLY) 1] No medical advice sought 36. Presently Under Yes No Yes No Yes ' No 2() Inadequate medical advice Current Best Care [333] Es) [558] 11.) Patient perati oe veranimeest ani tom dT on J NE i [550 IC] IF NOWith expert are [336] 37) 38] [560] [7] Availability of transportation a. Would condition I [561 10]” ....be improved? WC] 20Jf 10] 207 | 10) 2( F562) 1077 b. Would condition [579] 520) 520 permit Full Gain- Emp. or HW______ | 10 10] Part. Emp. or HW [2[] 20] 2] No change_______ 3] 3] 31 HSM-425-13A (PAGE 1) Form Approved Ev. 8/71 0.M.B. No. 68-R 1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE ASSURANCE OF CONFIDENTIALITY HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION All information which would permit NATIONAL CENTER FOR HEALTH STATISTICS Inara il HEALTH AND NUTRITION EXAMINATION SURVEY 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 fo OPHTHALMOLOGY EXAMINATION 15, Shs Ion Roy ther pifpesey a. Deck No. b. Sample No. c. Sex d. Age |e. Examiner No. |f. Name of examiner 1] Male 162 i a 2[] Female —_ A. SIGNIFICANT OCULAR HISTORY 1. Surgery — [] Strabismus [] Cataract 2. Other — [] Injury [J Infection 3. Other — Specify. 1] Yes 2[JNo B. VISUAL ACUITY [] Unsatisfactory test (Code 99 in space 023) ®@®® To Optotype used. 4 vous vin vouiwin in ibn 1. 1 [] Snellen 2. E 2. Acuity cc 0D 2. ¥en os @)_ _ sc 0D Ya 0s @) 3. If not 20/20, pinhole (Acuity) ....... 3. op Wm | *To be entered by coder] os @)- — C. MOTILITY Yo Tropa ous evs sven iis ERE 1% 1 [J Eso 2[7] Exo 3] Neither 1 [J Hyper 2 [] Not hyper 1 [_] Comitant 2 [] Incomitant Ri PIHGHD mi iosairinss win sehiese sani 2% 1 [J Eso 2 Exo 3] Neither , 1 [J Hyper 2 [] Not hyper L. 1 A 3 1 [J] Pendular 4] Jerk-rotary 2] Jerk-horiz. 5 [] No nystagmus 3] Jerk-vert. D. PUPILS i oD os ou | 1. Ani = Jogationss vs sve oH Han wi 10 2 J nisocoria — location | oO © 0 | Bor A) wresaricinin msn mnrivsrnin al 2. Absent light reflex : Bn; DIE. uous wrviins winin atv ale 2. | wi 2 1 b. Consensual, , b. i 10 2] i | 3. Other — Specify i | 0 @ oO 207 30) | 4. No abnormality . .......ers.osis. 4 | 10] 2[7] | E. TONOMETRY - Three readings i Applanation oD 0s a.m. Time of test p.m. | | ®@®® | | Anterior segment check prior to dilatation. i i I | 1 1 1 ! 1 | | | ! T | | DILATATION n (I git. 10% Phenylephrine OU) 1 i 1 | | | I | ' | | | i | ! 1[_] Not dilated: [] Suspicious anterior chamber [_] History of angle closure [7] Unable to instill gtts. 2 [] Mydriasis inadequate for fundus copy 3 [| Dilatation adequate H. MAXILLARY SINUS TRANSILLUMINATION (For detailed examinees only) To Rights vi mas was £04 Hes DEE SR 2 Lo 1 [Normal 2] Dull 37] Opaque Be Lal 1 sais sine woe Ha we £06 HORS 2 | 1 [C] Normal 2 [7] Dull 3 [7] Opaque NOTES 51 I. REFRACTION Eye Sphere | Cylinder | os] Tose] 037 038 039 1. Present glasses oD | 1+ 1+ 2 Dl 217)" {oe nitive of _ _ _ [om poan oz] for] [oa] os [T+ Cl \ BLY mss sme BY 21": cre stir se se Osiris 045 [0] [a7 [** [oa ]** [04s * + 2. If acuity less than oD (1+ 1+ 20/40, retinoscopy a | tr a) Et imi some i OF: nimi [052] 53 osafe* loss [** 056 os [+ 10+ * To be entered by coder 2[]- [——— — Df200-|— —.— Df _ J. LIDS oD 0s ou Vo Blophanits vc vcnnivioniv vim winin sininive Th 10 2) [3 ®@®@C®® 0 0 0 3. CONGTRIONS. v.10 vnerwinin momns i mincv ani cnn aie 3. $7 20] 3d 4. Ectropion . . 4. 10 20 3 RE 5. 0 27 30) 6. Hordeolum ............. IT 61 @) 1] 200 Nm) i Bodies consis i pak waa 7.1 @) 10 20 Nm] 8. Other — Specify 0 2] 0 9. No abnormality ................... con 9 0 20] sO K. GLOBE oD 0s ou 1. Enucleation - « 1. 10 2] 3 2. Exophthalmos « + ««vevnsesns oh dal 2 10 20] 3] Oe Measurement, . uu o oaivels aia a ae a. — ———— i b. Base... vine inanasaananans b. Sm 3. Microphthalmos . , .... At oA A eA Sear ae 3. 1a 2] s[] a. Measurement (mm) , .............. o — en me 4. Other — Specify 4 0 20 20 5. No abnormality . .. 5 10 2] 2 7 L. CONJUNCTIVA } oD 0s ou | Vo BABPERPOE. comme vows ssaiersie wes wiwin itot’s spot ! 10 2 3] 2. Conjunctivitis : a) AUEEIE vin vimor mens wise soma 2. | 10 200 3s i Be POITIER 40 3ins vow wie sia suis b.! 10 20) Hm] iy IEREHONE: is sins intone wide Hoe ly c. Infectious el a 200 3 (1) Bacterial — Specify, : | i m} 0 2] sO] | @) Viral = Specify 5 @] 10 2[J mi i . Folli i 10M). + vee . 3. Follicles (no inflammation) 3 10 2] 3s i 8 INCISIONS: 5 viv.simis wins 08 wimp onik pins 4! 10 2] 1 | Bx Plngueadlom says sin ae yok vais oie 5. i 0 20] sd | 6. Xerosis ...................... 6 | 0 2] 20 | 7. Other — Specify : | 7 @ 0 :0 Ya) 8. No abnormality « ................ 8. | Nm) i 3 | M. SCLERA ' op os ou | Re EOrasin viv veins vidin sinmminn sms sims : 3 ) crasia | 0 20 0 i ET 2. 0 20] sO) i Adi 1 —_ — 5 Seleitls wou svv cnn wwe 3 1 (0 2:0] 33 | 4. Other — Specify | | “1 @® 0 23 sO 5. No abnormality 5. | fm 20] 3] ! NOTES ** For detailed examinees only. N. CORNEA op 0s ou 1. Arcus senilis . . i 10 2] 30] 2. Band keratopathy . . ..... 10 2] 30 3. Degeneration — Specify. 0 2 a 4. Dystrophy — Specify_ 5. Edema 0 20 = a. Epithelial, ...... oui... @) 2] sO) bs (SWomAL i. un nam ve vn dvs 2] sd 6. Endothelial KP'S: «ui vais oxy eves 20 sO] 7: GREE: wus wa vein wR ORE 2] 3d 8. Keratitis — Specify 0 2] 0 9. Keratomalacia . ................ i 20 30) 10. Krukenberg spindle . ............. 0 2 3] 11. Opacity — Specify a =) 30 a. Superficial stromal 0 20] 0 12. Praryglumis i soo vn ins svn snnn ies 10 20 10 13. Vessels — Specify. oO m 14. Other — Specify ! ’ rs — TH 0 20] sO) 15, INO BONOHIBIEY «ve vn snes son vs ns 15. | @ i 20] sO 1] Location shown 16. Diagram location of abnormalities . . .. 14, oo os i | | | | ; 0. ANTERIOR CHAMBER | op os ou Te: Colon van wom war wei sve soos 2 @ OI 2] 3d Be FRE wis ws wove win svurw sarscorise 2] 0 2] sO 3. Other — Specify ____ | 3 m0 2] 30 40 Noabnorsality. .«eevvevnnnnnnn. 4 @ 0 2] 30] P. IRIS i oo os ou is ews wa vi wn ta. | © 0) 2] 3s] b. POSIEHOF. «ev svevanansnsen b.| 0 2] Nm) 25 POY. « sie imine 8 ERS HE SE 2 | ® 0 2] 0 Bs Colones voi us x sv ba ae vs 3! 3 20 30] 4. lritis a |} @ 0 20] 3] 5. Neovascularization ..-........... 5. 10 20) 3] 6. Other — Specify | | 6. | 10 20 3] 7. No abnormality ..... oo ...... 7. J! 20] 20] Q. LENS i op 0s ou Lo ARR se raw srg na v spsee LL @ oO 2:0 s0 2. Cataract | a. Immature . .. 2. @ 0 20 Am) be INtUMESCENt «vee nen b) @ 0 2] sd © MBI. «uv nvrrivr as smenne onl (2) 1d z[0 3] d. Hypermature « «ov ovovnn- “d | @ 0 2] 0 on MOPZREMIMN. «cov vw vena el 10 2] 3] > ii PONBE cine gms a. @) vy 20) 3 Be Cortical .uunreienneenns | 0 2] 2] Be NBER aso rs ermsars ie: el 0 200 a0 d. Post subcapsular. . ......... a 10 2] 3d 4. Pigment on Surfaces. sve vas se enen 4 @ 0 21 sO 5. Other — Specify | 5. | 3 10 20 3] 8s INDABTOIBINY, 1» + 255 eas w 4a evs wwe 6. i ® +3 2] 3] R. VITREOUS ! oD 0s ou 1. Detachment. . ..ovoveevneannnns I. | 0 20] 3] 2. HEmOrtHage + ovv sre nsenssnnnes 2. | @) 1] 20 3] 3. Opacity — Specify — | 3 | 0 2] Hu! | 4. Other — Specify ! 4“ @ Cc 2] 0 5. Noabnormality. .. «ove omens 5. LC 23 3[ 53 54 » RETINA i oD 1. Disc y 00 DIBBA: v5 ovis va neve la. | 10 b. Glaucomatous cup .,....... b. CF c. Neovascularization, , ....... c Ga) wy d. Optic atrophy (1) Primary + voovieinn an | @ 0 2) Secondary... . vivavinsn (2) Secondary. . . @ 1 @ 0 . . \ os Papilledema i, cua cnr wen e. |! (@) 10] £5 PARIS. os rm mminie LL @®0 g. Other — Specify. 9. a 2. Macula a. Degeneration Selle ou cnvsmnsnn @ 0 0 @® 0 (2) Disciform , b. Diabetic involvement . . . . . .. b. 10 eu Edema, oui suis visas iv c. (sD #1 d. Hypertensive involve ....... d. 0 e. Pigment epith. detach. ...... e. (B)] 1dJ f. Other — Specify. + 1 @®O 3. Vessels . Arteri ¢ br TY occlusion . , . .. 3a(1) (1) 10 (2) Central occlusion. @ 0 (3) Gen. narrow (1—4). . . . . @ G0 (4) Sclerosis (1=4) + +... (4) 0 b. Veins (1) Branch occlusion - + . « « b(1) 10 (2) Central ucclusion - - - « « @ "Ol 4. 5. . Other — Specify . No abnormality . . . (3) Dilatation « +e vnnnun 3) OO (4) Sausaging +... eonnn (0) 10 (5) Sheathing «+ vvnns (5) im) (6) Torwosity «vou... (6) 0 . Capillari Eg *0 Microaneurysms dew Sie (1) 10 i i i i | i (2) Neovascularization, ... (2 | Oo i d. Other — Specify. } i i a 0 Exudates a. Cotton wool a "OJ bs Hard. on vin sivn wb i & Wangs sium sie sis Bom see y @ 0 d. Other — Specify. ! i « 1 @0O Hemorrhages a. Choroidal 5. | (DO b. Preretinal be @ 0 €. Retinal. ..... cee (1) Deep on) @ 10 (2) Superficial ...... al @®o d. Other — Specify. “i@®0 Pigment changes a. Choroical ,..evvvveancees ba. [X=] b. Epithelial (1) Atrophy. «vvvvvenns 0) 0 (2) Hyperplasia. ........ @ 0 c. Other — Specify. c F® 0 oy Angiotd Streaks . .. ¢vie suit sive on 7. “W Detachment + « eee coconnnacsens g @ 0 Drusen ++ veneenenncnnenene oo | (@) 10) Inflammation a. Chorioretinitis — Specify. 10a. 0 (ND Active se vsorasnransanne m 1d (2) Inactive « + + sears cannns (2) | Retrolental fibroplasia . .......... 3 @® 10 | | 1 | i i i 1 i | i i i i | | 1 | | | i i 1 | | i Not visualized . . . 0s 20) 200 20 20) 20 20] 20] 2] 20 20 2] 20 20) 20) 2] 20] 2] 2] 20 20 20] 2] 207 2] 2] 2] 2] 2] 2] 20 20 20 20) 20] 20) 20) 20] 20 2] 2] 2] 2] 20 2] 20 2d 20 20 20] 2] 2] 2] ou 0 20 30) 50) 20 0 20 10 sd 30] 10 10 3 20 Ld 3] sO sO) 30 sO) 30) sO) sO) 30) 30) 30 sd 301 3d 30 3:3 3d sd 30d 20 33 10 30 30 sd sd sd 3d 3] 10 s(] i Li 3d 30 3 sd S. RETINA - Continued, 15. Diagram location of retinal abnormalities 1 [] Location shown T. OPHTHALMIC DIAGNOSIS 1 [J] Incomplete examination 2 [] No abnormality 3 [_] Abnormality Mark column applicable, leave blank if unknown Code Condition Treatment Eye affected decreases vision Needed | Under | Not, op 0s ou 193 194 195] 196 i P 1] Yes 1. Amblyopia «..... 1 [C] Present 2] No 10 200] sO 1d) 200) =O 2. 197 198 199 200 1] Yes i 2] No I) 203] 20] 13] 20] =O 3 201 202 [203] 204 [Yes A 2 [J No Of 203] =O 10) 20s 4 205 206 207, 208 1] Yes a 2] No 1] 20] +O Of 20 sO 5. 209 210 211 212 1] Yes TT. 2LJNe 10 20] 0 1d 20 0 6. 213 214 215] 216 1[]Yes er a Tat 2 {J No Wl 200 ed 1014 201] sO NOTES 55 56 DEPARTMENT OF HEALTH, EDUCATION AND WELFARE PUBLIC HEALTH SERVICE HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS ROCKVILLE. MARYLAND 20852 HEALTH AND NUTRITION EXAMINATION SURVEY IV DENTAL EXAMINATION Confidentiality has been assured the individual as set forth in 22 FR 1687 NAME 6 0 6 0 9 Mono o # “ae “4 4 4 ONTROL 5 5 re: o > oo o 28 nl: $2: iS: ode: TENS = UNITS -:5:- MW EW MN ° 3 EXAMINEE hn 5 G- 1 - 7: rn UPPER LEFT LEFT LOWER RIGHT o x sR: =k: af: 88 i occ LIN BUC MES DIS ~>R—ZmO =O AX: -5%:| OCC -50-| LIN =5t:| BUC -52:| MES -&3:| DIS 4X occ LIN BUC MES DIS fe =8X-| OCC -50:| LIN -5t-| BUC =52:| MES -63:| DIS Berolthrsroltp occ LIN BUC MES DIS O—o0ncH IR -5%:| OCC 50:| LIN =5i:| BUC -52-| MES -53:| DIS eo pB A BexaReBREBR2BRERR ES BB 4 2 Re occ LIN BUC MES DIS O=oNCH—® 4 -5%-| OCC -50-| LIN 5t-| BUC MES DIS geslapegebbRegRsBReBRE age FD. $ h|B B® Db D x ER2BRE occ LIN BUC MES DIS N Zz o O—onCOH—m eB h LIN BUC MES -53-| DIS 52 53- 1R: -5x-| OCC 50 51 52: en EH DDD x ap e28Rr3 occ LIN BUC MES DIS «0 4 op—0Z ED: -5%-| OCC :50-| LIN -5t-| BUC -52-| MES -53:( DIS GpesREREReB EE evs FEVEREEREEEE REE eee ee eee eee eee eee eee i eee eee ee ee eee ee eee eee ee ee eee ee eee eee eee rere ee er en DENTAL EXAMINATION EE ws age gg STAND 28: % 8 Fe: ues AND Ee ug: ul: cape gs og] CONTROL SE ce pC EE Qs mgs mgs upc ug ng: gs =g: gf UPPER LEFT UPPER RIGHT LOWER LEFT LOWER RIGH XD 3: (20 HR XD ug: WOT XB: ge: AR BX 3: 0: AX BX| OCC |-8x =3: =@: 4X :8X| ND OCC |:6x: 5%] 80 40 :50| LIN |:60 40 50 8 LIN | 60: et =at =5t| BUC |-&¢ ar cer| Xk BUC |-8t 81: 82 =f: =R: AZ 82 | MES [82 a2 ws2| MES |-62- 52: $3 £0 RD 43 :53| DIS [83 43 5% DIS |-63: -F: 43: 53] XD Xo EPS Sr Xo: so CHR “8X OCC |:8% =3: =@: 4X :5%| 3pp OCC |:6x ax: 5X “80 LIN |:8c 4a 8 LIN |-s0: ET BUC |:8t: 4 i 62 MES |-82 a2 R MES |:62: gE FD 63 | DIS |:83 FB RB 43: 83 EB RB 43: :53| DIS |:63: PERIODONTAL INDEX oo Td PERIODONTAL INDEX OPACITIES QUADRANT | £ _ i= > £_ 2 > | QUADRANT 32 NOK. =8%Z| space |5=BZ i FLUORIDE af i Fh Ld £258 il i i i NONE Bn 1 : 1 (i oo Hr ns 3RD MOLAR | #7 +E - MODERATE- 2ND MOLAR | 1:8 8 48 48 48 SEVERE 1ST MOLAR | =4-& 19 19: 49 He: fe UPPER LOWER RCH Mos es ARCH 20: 2 2% «20 OTHER CONDITIONS A oe wa |e | 0 21: -2t 2h -2i: YES | NO cusp | 22 22 22 22 -22 SLEDS LBUNY DIFFUSE MARGINAL LATERAL 2% 2% 2% 25 25 INFLAMMATION SWOLLEN RED CENTRAL 24 24 24: 24: PAPILLAE 2 2 X T z 8 RECESSION 9: CENTRAL 25 25 25 25 -25. |FOUR OR MORE PAIRS OF OPPOSING SERVICEAI 10: HO LATERAL 26 :26 26: :26: 26: |POSTERIOR TEETH PRESENT ee be adr ae A:t CUSPID 2 27: BN 27 wen ABSENT UPPER LOWER 42: HE HE HE 2 1ST BI 28: 28 -28 -28 :28 |ORTHODONTIC PRESENT ARCH ARCH 4S HE HE 4 43 | nom | -29 29 29 :2¢ 29 | APPLIANCE ABSENT LEFT RIGHT 14: cha 1A 14 1A: | 1ST MOLAR 30 30: 30 36 30 15: HE UE HS 1:5 | 2ND MOLAR | -31 Eh &: BE: EE 16 46 46 HE 216: | RD MOLAR | -32 BE 32 BE BE UPPER ARCH ORAL HYGIENE INDEX LOWER ARCH RIGHT ANTERIOR LEFT RIGHT ANTERIOR LEFT DEBRIS CALCULUS DEBRIS CALCULUS DEBRIS CALCULUS DEBRIS CALCULUS DEBRIS CALCULUS DEBRIS CALCULUS 20: NONE 2:0: #0: NONE ::0: 0: NONE 0: z@: NONE -:Q: z@: NONE :-@: NONE --@- 3 sk: Wg od mt V3 3 3 v3 npr 2/3 2: #nes 2/3 ug: wR: (2/3. wg: ug: 2/3 ue: wr 2s ner 2/3 3: 2/34 3: 2/3+ 3: 3: 2/34 3: <3: 2/34 3: <3: 2/3+ 3: : 23+ CNA CNA SINAC NA INA SNE NA INA | NA “NAC 57 58 DENTAL EXAMINATION ce <6 = cE 2g: 2x uB: ue wer whe Tl whe Gy fe alt 8s CONTROL = Fr 28: afc wh: we “4s 5c wee afc 8: ny BUCCAL SEGMENT RELATION POSTERIOR CROSSBITE ENAMEL BIOPSY | MESIAL-SEVERE [Focesc "agua [poceAr GURY no: TEETH ABSENT ~MODERATE Ne: EQUIPMENT FAILURE NORMAL no: OTHER REASON ==4: | ==: | DISTAL-MODERATE Eo 5: -SEVERE YES aoa: | sens [NOT APPLICABLE 4: 4 wl 5 PRIMARY ARCH NA NA NA NA: HLD INDEX (HANDICAPPING LABIO-LINGUAL DEVIATIONS) OVERJET un INCISOR RELATIONSHIP OVERBITE OPENBITE ASA DEFORMITY wr wife [a8 al OPENBITE (MM) © ul we ol 0 ABSENT =e: 4+ ug: ngs 2+-4 sis wd ol PRESENT 5 Ege (eR = =F: 0-2 2% Bz ok = 4 OVERBITE 4 x =: 28 ==&: INC 3RD 2:5: 25 6: 6 5: MID 3RD 26: to] Ee =f: =:6: GIN 3RD 7: ==: 8: 8 zz7-z TISSUE whe 8: 29: 9 zB: IMPINGING OVERBITE 9: 28k SNA 5 A= NOT APPLICABLE NA NA NA MALALIGNED TEETH EDENTULOUS ARCHES-DENTURE STATUS UPPER “NA: ABSENT PRESENT DEFECTIVE ANTERIOR UPPER 2 0: =: 4: MINOR =5: 6: LOWER “0: =: Er id: MAJOR =: 6: WHEN YOU EAT, POSTERIOR DO YOU USE AN UPPER PLATE? wr 8: 6: DO YOU USE A LOWER PLATE? “0 <3: 4: MAJOR =5: =: REMARKS: PRESENT ABSENT ----- LOWER POSTERIOR 0: 2: Br uk: MINOR =5: =: =P: =8: =@: Qe mfr nmPr nBr EMAJOR mB: =€: =P: m8: Ee EXAMINER 23 2B: RECORDER 2%: sof: 2B =f ul: sees uf 2B DENTAL EXAMINATION © In 2p: 8: ag sg =e Px ng: =r STAND gE fm ug 4B Her wre Ea AND 0 pr wS: ngs ug: =@ Po =f: CONTROL © 1 2 t Sue 29% wir sy ul gr nS: ug: nl wl: TREATMENT NEEDS INTERVIEW DO YOU VE AN UBLE; YES NO NO APPARENT NEED FOR DENTAL CARE HAVE ARE REMOVAL OF DEBRIS AND CALCULUS CHEWING STEAKS, CHOPS OR FIRM MEATS? GINGIVITIS TREATMENT BITING APPLES OR CORN-ON-THE-COB? PERIODONTAL DISEASE TREATMENT BITING OR CHEWING ANY OTHER FOODS? SEVERE MALOCCLUSION TREATMENT 0 I 2 3 4 5 6 7 8 9 ===:= DECAYED PRIMARY TEETH 222 TENS ONE-SURFACE FILLINGS TWO-SURFACE FILLINGS THREE (OR MORE)- SURFACE FILLINGS EXTRACTIONS DECAYED PERMANENT TEETH ONE-SURFACE FILLINGS TWO-SURFACE FILLINGS THREE (OR MORE)- SURFACE FILLINGS EXTRACTIONS = EXTRACTIONS, PERIODONTAL DISEASE EXTRACTIONS, OTHER ..... FIXED BRIDGES AND/OR PARTIAL DENTURES INDICATED REPLACING TEETH NO.'S UPPER ARCH LOWER ARCH NO. OF BRIDGES NO. OF PARTIALS sn zzzio REPAIR OR RELINE OF REPAIR DENTURE OR BRIDGE RELINE ===: CONSTRUCT DENTURE(S) == UNITS TENS == UNITS TENS UNITS TENS UNITS TENS == UNITS TENS UNITS =: TENS UNITS TENS UNITS TENS UNITS TENS FEEEETETTET 17: 8: 19: 20: sot: 220 23 25 26: 27: 28: 20: 30: :3t 1 2: ul: whe ae a6 gr age he gn GE FU. ss EW, ms 59 60 Confidentiality has been assured examinees as set forth in 22 F.R. 1687 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS ROCKVILLE, MD. 20852 HEALTH AND NUTRITION EXAMINATION SURVEY REPORT OF DENTAL FINDINGS Dear Doctor: Recently the person named in this report was among those who had voluntary examinations at special mobile facilities operated by the Public Health Service. The dental examination of the Health and Nutrition Examination Survey is not, and is not intended to be, a substitute for the examination usually given to persons seeking care from their own dentist. Neither a dental history nor X-rays are taken, and therefore the findings are solely the result of what can be seen at the time of the examination. The examinee named in this report requested that it be sent to you. If you have any questions about the Survey, please write. Sincerely, Hee Hy BA. LAWRENCE E. VAN KIRK, D.D.S. Dental Advisor Room 8A-54, Parklawn Building Rockville, Maryland 20852 Form Approved; O.M.B. No. 68-R| 184 Examinee’s name and address Age Date of examination THE INDEX ASSESSMENTS USED IN THE SURVEY REVEAL: ad No conditions which suggest that the examinee should be seen by you before the next regular appointment. O One or more of the following conditions that suggest a clinical examination is desirable to determine whether or not treatment is needed before the next regular appointment. [[] Decayed teeth [C] Oral debris and/or calculus [[] Gingivitis and/or periodontal disease [J Malocclusion [] Other conditions — Specify EM-425-14(B) (PAGE 1) Confidentiality has been assured examinees as set forth in 22 F.R. 1687 REV. 5/71 DEPARTMENT oe HEALTH, EDUCATION, AND WELFARE UBLIC HEAL TH SERVICE NATIONAL. SENTER FOR HEAL TH STATISTICS OCKVILLE, MD. 20i HEALTH AND. NUTRITION EXAMINATION SURVEY REPORT OF PHYSICAL FINDINGS! Dear Doctor: Recently the person named below was a sample person who voluntarily participated as an examinee in the Health and Nutrition Examination Survey conducted at special facilities of the U.S. Public Health Service. The objectives of the Survey are to obtain information on the nutritional and general health Jae of the U.S. population. The examination is not, and was not intended to be, a substitute for a visit to the ician, nor was it i d to be a plet: ion. At the request of the examinee, however, we do send a report fos cetdln selected procedures to his/her physician. Reported below are physical findings which our physicians (including an ophthalmologist and a dermatologist) 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. Sincerely, Prete Loewrerlls FRANK LOWENSTEIN, M.D. Nutrition Advisor Form Approved: O.M.B. No. 68-RI184 Examinee’s name and address Date of Age Height examination Sex Weight MEDICAL DERMATOLOGICAL OPHTHALMOLOGICAL VISUAL ACUITY [CJ No new significant findings | [7] No new significant findings | [] No new significant findings R Eye L Eye 1 20/ 20/ 1 | I I I 1 I I 1 [] Without glasses [C] With glasses [C] With contacts | [] Not tested 1 Hematocrit vol% URINE Neg Tr 1 2 3 4 Hemoglobin _____ gm% Albumin RBC count —_— mille Sugar WBC count thou/cc Ph Os Os Or Ole Cle Sed rate — mm /hr Hematest [CJ Pos [JNeg fii SEE REVERSE SIDE FOR NOTES ON TESTS AND PROCEDURES This form is used tor reporting significant findings of examinees receiving only the nutrition component. The form reproduced on page 76 is used for reporting findings of examinees receiving the detailed component. 62 NOTES ON TESTS AND PROCEDURES Medical Examination — A physician, a dermatologist, an o Wjiakglogst, and a dentist examined each examinee. The physician’s examination included the head and neck, chest (cardiopulmonary), abdomen, and extremities (musculoskeletal and neurological) -- however, rectal, pelvic, and breast examina- tions were excluded. The dermatologist’s examination supplemented the physician’s skin ex- amination. The ophthalmologist’s examination included visual acuity, slit fa scopic visualization, and tonometry on examinees age 20 and over. Hematology — Screening limits *** Urinalysis — Dip and read method using Ames Hema-Combistix. amp and ophthalmo- Micro- Cyanmet- Coulter Coulter Wintrobe Determination hematocrit hemoglobin counter counter Sed Rate Vol. % Hgb Gm% RBC /cc WBC /cc mm /hr Age 1 231 210.0 3.8 -5.2 mill. |7.0 — 16.0 thou. - Ages 2 — 11 234 211.0 3.8 — 5.2 mill. [6.0—15.0 thou. ** - Males 12 — 16 yrs.* 239 213.0 4.5 — 5.5 mill. [4.5 — 10.0 thou. - Females 12 — 16 yrs. 236 211.5 4.2 — 5.2 mill. [4.5 — 10.0 thou. - Adult Males 41 —- 52 14.0 - 16.5 4.6 — 6.2 mill. |4.3 — 10 thou. 0-9 Adult Females 36 — 48 12.0 — 14.5 4.2 — 5.4 mill. [4.3 — 10 thou. 0-20 Pregnant Females 33 — 42 10.5 — 14.0 | 3.7 — 4.9 mill. [5.0 — 12.0 thou. 0-30 * Marked variation with age for hematocrit, hemoglobin, and red blood cells for males in puberty. ** Marked variation with age for white blood cells in age group 2 — 11. *** Results outside the screening limits are considered to warrant further investigation of the examinee Clinical Chemistry ~ Laboratory tests on blood and urine 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 and which were outside the screening limits *** indicated. If additional results outside the screening limits are received, they will be forwarded to you promptly. Otherwise, you will know that all values were within the screening limits. BLOOD Test Result Screening limits *** Test Result Screening limits *** Vitamin A (P) __ug% 20 — 100 ug % Total protein (S) __ gms % 5.0 — 8.5 gms % Iron (S) — ug % 40 — 200 ug % Albumin (S) — gms % 3.0 — 5.5gms %. 1.B.C. (S) — ug % 240 — 400 ug % Cholesterol —mg % 260 or less ug/gm Folate (S) mug % 5 — 30 mug % | Iodine (U) — Creat. 50 ug or move Vitamin C (P) mg % 0.2 -10.0mg % | (P) = Plasma (S) = Serum (U) = Urine APPENDIX 1IP. NUTRITIONAL BIOCHEMICAL LAB DATA FORM (ALL EXAMINEES) HSM 425-6A HEALTH AND NUTRITION EXAMINATION SURVEY REV. 6-71 —_— EE an CDC-NUTRITIONAL BIOCHEMICAL LAB. - DATA RACE HOUR OF CARD | SAMPLE NO. SEX AGE EXAMINATION DATE COLLECTION HEMATOCR{ HEMOGLOB. YEARS | MONTHS | MONTH | DAY YEAR 1Jam 801 Jem nn a ct py GMS % (1-3) (4-8) (9) (10-10) | (12-13) [(14-15)](16- 7] (18-19) (20 - 21) (22) (23 - 25) (26 - 28) Hours since last meal: Physical activity in past 24 hours: 2s, 36) (47) 1] Nene 2 7] Light 3([JMod. 4[] Heavy Last meal was (31) 1] Light 2 [] Med. 3 [] Heavy Has examinee taken within last 30 days: Days |Date shipped Vitamins (32) 1[] No 2[_] Yes - last taken (33, 34) Minerals (35) 1] No 2[_] Yes — last taken (36, 37) — | # of blood vials shipped 0 1 2 34567 8 9 10 Aspirin (38) 1[_] No 2[_] Yes - last taken (39, 40) — | # of urine vials shipped 0 1 Diuretics (41) 1[_] No 2[] Yes — last taken (42, 43) REMARKS-NURSE REMARKS-LABORA TORY Other medication prescribed by doctor: (44) 1] No Factors that might affect nutri'l. 20] Yes stat. at time of exam: Lost taken in days (45-46) Type of prescribed or other medication RACE SEX CODE 1-WM 4-WF 2-NM 5-NF 3-OM 6-OF 63 64 APPENDIX IQ. EXAMINATION FORMS (ADDITIONAL FOR DETAILED EXAMINEES) Form Approved HSM425-1A OM.B. No. 68-R1184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY qa Hecicatn or “he ndiviuat i HALT AND NUTRITION EXAMINATION SURVEY ied ony By” Sarsons sniaged be CONTROL RECORD and will not be disclosed or released to others for any other purposes (22 FR 1687). a. Name (Lost, first, middle) b. Deck No. c. Sex 201 1 [Male 2] Female d. Date of birth e. Age f. Examination date g. Temperature Month Day Year Month Day Year an] ID. Time NOT Procedure or part of overall PROCEDURE DONE STAFF procedure not done IN out (Enter reason for non-completion) 1. Casual specimen x [J 2. Body measurements x [J 3. Xeroys x OJ PREGNANT @9)1 [J Yes 2[JNo 4. Physician's examination xd 5. Yenipuncture x] 6. Tuberculin test x01 7. Dermatology x [J 8. Ophthalmology | x] 9. Ophthalmology 11 x] 110. Dental examination x [J 1. Avdiometry xO 12. ECG and Spiro x0 peg jprens 13. Lung analyzer x0 14. Goniometry x 15. Nutrition questionnaire x] IN HOME 1 JYes 2[]No 16a. Supplement A x] b. Supplement B x0 c. Supplement C xO 17. Health care needs x] 18. General well-being x [J OFFICE USE ONLY | TIME IN TIME OUT Sample Number @) nO @) vO HSM4254 (Pace 1 Form Approved REV.11/71 0O.M.B. No. 68-R| 184 . ASSURANCE OF CONFIDENTIALITY DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE All information which would permit PUBLIC HEALTH SERVICE identification of the individual will HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION be held strictly confidential, will be NATIONAL CENTER FOR HEALTH STATISTICS 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 to others for any other purposes (22 FR 1687). GENERAL MEDICAL EXAMINATION Deck No. 232 pe. DRUM — Continued I 1 I . | | Right left 10.Red «oun... 0 @ 0 @0 1. No findings — ) . . ! 11. Other discolorations 11, | ___ 20] ~~ 2[] SKIPtoB ...... 1. Lo 0 @) OI + lo I I I | P> A. EXTERNAL EAR (Except canal) 2. Findings — 12 FWIY suunsnna 2 | 0 10 Conti ith3 ..2. onic with 3 cet —— SW 13. 5€0r8 vu nvr na 13. | @) 1 1 | @ BJ 'U 14. Perforated a goa 4. Other — Describe . 4. | @ 0 @'O a. With discharge 14a. | 10 @D: a 3. Operative scar... 3. | b. Without discharge . b.! 2 [J 2] weer miait oes fy ati 58 oy mye PD. NARES | Right Left 5. Pierced ears ....5. ! 1 [J Yes 2[JNo CL ! A 1. No findings — p> B. AUDITORY CANAL | Right Left SKIP 0g «uvunnle | Oo 00 1. No findings — 2. Findings — z YA | OJ 7 Continue with 3 . . 2. 20 20] 2. Findings — = 0 3. Obstruction ! i i * 2 Acute ....... . ! 1 Continue with 3 .. 2. I. I. a. Acute 3a Od | 3. Occluded: : b.Chromic sc vnns b. 2] 2] 5. PaIEially wu 3a: +3 vy 4. Other significant JE b. Completely. ... b.] 2 2 findings — freee 9, @.0 @.0 I 4. Occluded by: a. Deviated septum . 4a. | o. Cerumen ..... “ [J @ 1 b. Swollen turbinates b. Ld 1 [O (039) 0 b. Other — ibe b.! rm ther — Descri 2 30 c. Chronic inflammationec. | 1d (DE (8 d. Other —Describe . d. | ¥ J @o) 0 C. DRUM Right Left I I | | } 1. No findings — ® sl yO I | 1 1 1 | | SKIPtoD ...... 1 I | i > E. NECK 2. Findings — . Lo | Continue with 4. . . 2. 2] 2] 1. No fodings = . 0) [J 3. Not visible ..... 3. 3) 3] g Eilis ’ : 0 Ne rr Ten Bi en tie] . -— 1 4. Dull (Opaque). . . . 4. | 1 [J yO Continue with 3 .. 2. ! 2] 5. Transparent . . ...5. | 2] 2] 3. Adenopathy ..... 3. OJ i Sr ee] " I 6.Bulging ....... 6. | ' 3 OJ 4. Tracheal deviation. 4. : v1 7. Retracted . ..... 7 | 2 7 2] 5. Other — Describe. . 5. | 10 8. Calcium plaques . . 8. | @® [J yO | | 9. Other findings — Pe... ee ] Sample Number Describe . ......9. | 02) [J @ 0 I | | 65 SE : PF. CHEsy Rimin. pbien: Bronchial Rales Rhonchi | Wheeze 1. Auscultation sounds | °° ose Tanti - Right chest : } ¢ @ Opetinaings- |" [@ 0 0 | @ 0 |@ 0|@ 0|@ OC | 2 [] Findings Middle tobe] 030) 1 (1 | 20 | ©) + 3 [@s9) + OI @) Oe O | Lower lobe 09 01:0 0) ©) CO @) + [Ed * TO Left chest | ee @ 10:0 ® 1 0|@ 0]@ C@ oO ried] @ 10 0] @ 0 |@ 0|@ 0l@ 0 2. Other chest findings 1 [C] None 2 [] Findings PG. HEART LPM 2500s es rrmpensranyms '. | 1 [] Felt 2 [] Not felt | | 2. IEISPACR + vv nurs vivennennen 2. | @9 4 5 6 703 | 3. Midclavicular line . .. .......... 3. | @ 1 [J At 2 [] Inside 3 [] Outside I Ae THINS «wns nnnenvmans sms ios 4. i 1 [] Absent 2 [] Present | w SYBIONEL we nm nny manus seer - B A a. dy « @&-0 ase 2 [] Apex Bb. Diastolic curv vmvmnmnmnses ve b. : 1 [] Base 2 [] Apex | 5. Heart sounds a. Istheartsound ............ 5a. | 1 [7] Normal 2 [[] Accentuated 3 [] Diminished | b. 2nd heartsound ............ b. i 1+ [J] Normal 2 [[] Accentuated 3 [] Diminished Bi MUMS - + a5 saw ssw saos ve so® 6. i 1 (J None — Skip to 7 Eo te ct een St teh ee rere i ST SYSTOLIC MURMURI(S) DIASTOLIC MURMURI(S) 05 TYPO vv tie inv swininnw © «wie niin a. | 1 [J Functional 1 [J] Functional 2 [] Organic 2 [7] Organic 9 (CJ Don't know 9 [T] Don’t know b. Location [TTT TGRaee TTT craDE | I (Apex ......covvvienns b(1)! 1[J2J Je ds Je 1[J2[J3Je Js Je | ce ec ss so A So tet (2) Midprecordium ........... @! 1s es Ce 0 (089) 1 [20s es Ce m3 TE aS a 1 | | (3) Lefebase. .....oounn.... 3)! ese 0s @D1[T2(Js0e se 2 Sr com coe ti oS. SS oo. vo. ov st | \ | (4) Right base ............. @) 1s Ce] @) 12006506 ] Sample Number Continue with 6c, ‘‘Origin’’ on Page 3 HSM-428-4 (PAGE 2) (11/71) 66 PG. HEART - Continued | | 4 Murmurs = Continued Systolic Diastolic Both c. Origin ! (Mitral. ovoeeeennennn. 6e.(1) | vO 2] i (2 AOTC. + veeeeanaennn . 10 20) 30 (3) Tricuspid... ovueennn.s 3)! yO 20] s OJ % | (4) Pulmonic ........c.... (4) | 10 2] 3] BIASD ..vorvvinssnonne OF 0%8) + 2 [J 3] BIVED ....iivesensnmns ©! (@» +O 20 3] GYOUEr civ sp sm aes whe Mm (Goo) +O 2 [J 3] I (8) Don’t know ............ (8) | (lo) + 7. Other cardiac or | cardiovascular findings 1 [J No — Skip to H 2[] Yes — Continue with7a 0- Edema ...covevsnnsnnain 7a. 10 b. Other — Describe .......... b. | 1 [J I I | | c. Neck vein distension. ....... c | 1 [J I H. PULSE - ARTERIAL EVALUATION | Sclerotic and 1. Palpation Normal Sclerotic Tortuous Tortuous a. Rightradial ....oovuuennn. lo. |! 10 2) 2 [J O b. Right femoral ........c00.. b. | 10d 20 3] «0 c. Right dorsalis pedis ........ c. | 1 2] 3] a] doloftradiol.....eovvvsoess d | (ow) +O 2 [J 3] «0 os. Left femoral ...sossnvevns e. | (10) 13 2[J 3) | i f. Left dorsalis pedis . ........ f. (@) 1d 2 3 [J | 1 2. Pulsations Normal Diminished Bounding Absent a. Rightradial ..oovevueenens 2. | @ 1 [1 1 sO IE b. Right femoral . «oo ovvunnnn . b. 0 203 3 (3 OJ ¢. Right dorsalis pedis ........ c | (@) 1 20) sO «O d. Other — Describe «....oone . d i @ 1 OJ 2] + om | | I | o Leferadiad ous cnsnnnnnsnny e. 1 (MoO 2 20 «0 f. Leftfemoral ............. f. nw) +O 2] | «dd g. Left dorsalis pedis ......... % | Gw) +O 2] sO) «0 h. Other — Describe . . . ........ he ) 'O 2] 3d a] | I ) Sample Number | | HSM-428-4 (PAGE 3) REV. 11/71 67 > I. KNEES ® 1 [] Findings — Continue with 1 2 [] No findings — Skip to J Sample Number I | 1. Bony irregularity ; R L Both a. Genuvarum ........ CREE la. | @) 1 [J 2] 3] be Genuy VaAIZUM «assumes sss b. (2 1 J 2] 3] c. Genurecurvatum . . «cove ean c. (2) 1 2] 3] d. Fixed flexion ............... d.| 1 [0 2 [J] 3 e. Other — Describe || 0 0 . (11-3 e. | (29) 1 2 3) | | 1 2. Pain on motion | Act. Pas Both Tenderness a. Right medial ............... 2a. | yO 2] 3] 2 O b, Right 181818) . , ov vvsmmmnnny be | ‘2 | 1 2 [1] 3] 1] €Rightdiffuse ,.csvvsnsnnsimns c. 1dJ 2] 3] (3) y [1 di Lefrmedial oc cvsnannininaa d. | 1 [0] Pm 3) 1 [J | e.Leftlateral ............... -| & yO 2] sO] 2 yO ] | f. Leftdiffuse ....vvevennennn. f. ! 1 [OJ 2] 3s [J 3) 1 [J g. Right suprapatellar .......... $l) commrensensin oe SRC EAE ® . (139) 1 [J h. Left suprapatellar . .......... hel veneennnn Fate vie Sh ’ . (139) 10 Lo Cd i. Right infrapatellar........... i. ho 6 0 a Re i EE (40) 1 [J j. Left infrapatellar. ........... 21 Banis oa SPR RE EEE sess va. 1 ! ONS 3. Other findings | R L Both | a.Swelling ....ivivennnnnnn. 3a. | @) 1 [J 2] 3 be Fluid ousuavivanenronsus bi (43) +O 20 0 c. Soft tissue proliferation ....... | (ww 1 [0 2] 3 d. Subpatellar crepitus. . . .. ..... d.| 4) [1 2 [1] 3] e. Muscular wasting thigh. ....... e.| 1 [1] 2] 3 I f. Other — Describe ........... f. | (a) v2 2] 3 | I PJ. HIPS 1 [] Findings — Continue with 1 i 2 [1] No findings — Skip to K I : ACTIVE PASSIVE 1. Pain on motion | R L Both R L Both I G EXIONSION oo vvsinivsnvnnmn lo.! (9) 1 O 20 (1 dO 20 00 bo FIEXiON «vv vv ve eevee eninnn bi Qs) + OJ 21 sd (sd) 1d 203 0 c. AbdUCION «vv vie eee cl (s) 10 210 30) sp +O 201 3 d. Adduction + eevee eennnnn.. d.! (59) +O 20 3:0 Gs 'O 20 0 GER IOL: iiss issnanammnnne el (5) 'O 20 sO 10 20 100 | fo INL TOL «viii eee HO 2:0 sO 1 230 sO I I I I I HSM-4285-4 (PAGE 4) REV. 11/71 68 L/VE *A3N (8 IDV) V-SZV-WSH J. HIPS — Continued 1. Other findings 1 | R L Both 1 a. Muscle wasting (gluteal) . . o.oo uuu ne enna. la. ! 1d 2] 10 be Trochanter tEndRIIeSS. « + ws vo « +3 in 8 $5 5040 win 3 b: #7 [J sO) €. Groin tenderness « «vou ove tune | 1d 2] 3] d. Other — Describe | OO 2) 3) pK. JOINTS J 1 [J No findings — Skip to L ’ 2 [] Findings — Describe and continue with 1 MANIFESTATIONS Other , joints Tender Swelling Deformity Limitation Higbardep 3 Pain on motion Other ? R 3 1B R3[ JB R B B 8 1 Shoulder PD eo ED ICE IG R 2 Ei @ 1LIR Cle @ R08 @), re @9, Or Coe (9 CR 2s @; gr Cs 3. wrist @ LE @ Lf UR |, LE | Le @ L705 Ge us RIGHT | LEFT | RIGHT LEFT | RIGHT LEFT | RIGHT LEFT RIGHT | LEFT | RIGHT LEFT .M - ivi I © | © C&O 1 B.06 BO (No. involved) 2] 2] 2] 2] 2] 2] Lh 200 2] 2] 2] 2} 3s] sl 3] 3] 3] 3] 31 3) 3 3] 3 3) «0 «J «J «J «J Lm] «J «J 4] Lm) «J 4] s[] s[J s[] 5s] s[] 5] s[] s[C] s[] 5s] 5] s[J (199 (09 some [mA RB S| 188 _&_ a e129 inter- 2[] 2) 2) 20 20) 20 2C) 20) 20 20) 20] 2] phalangeal 3] 3] 3 3) 3) 3) 3) 3] 3) 3} s[] s[) (No. involved) | + 4["] | | 4] a] | | a] a] oJ | aC] 57] s[) s[] s[] s[) s[] s[] s() s() s(] s[] LI] @ [@ @ |@ |@ @ 6. Distalinter- ld 1d 10] 1 | 1] 1c) OJ vl 10) rd vid phalangeal 2] 2] 2] 2] 2] 2] 2d 2] 2[] al} 2] 2[] (No. involved) 3] 3] 3] s[] | 3] a] 3] 3] 3] al] 3] «J a[] a] a] a] [1] «J «(0 a] a] «J «[] s[] ss] s[] sO sO) s[) sC)| sO ss) si} sO) sO R “IR 3 B TAM @ i 08 @); LR 0e @) Re @) Lr @9) CR 200 @), Or Oe R B R B 8. Feet ee [ERE [EAE (ORE = el [EN 69 » L. BACK 1 [J No findings — Skip to M | | 2 [] Findings — Continue with 1 . | 1. Scoliosis ...veeee.. lo @) +O 2. Kyphosis ........ 2 | @9'O 3.Lordosis . .ooveeennnn 3. | @) 10 4. Tenderness a. Sciatic notch ....... 4a. | [OR 2JL 3 [J Both b. Sacroiliac ..co0 vee. b.| 1 JR 2JL 3 [J Both . Other — Describe ! v c 1 | O I 5. Limitation of motion : a. Cervical spine ...... Sa. | Qa) 1dJ b. Thoracic spine ...... b. | @ 1d c. Lumbar spine flexion . . c. | DD) 10 | d. Lumbar spine, right | lateral flexion. .... d.! Qu) 1 e. Lumbar spine, left lateral flexion .... . 10d f. Full extension ...... f! (240) 1d 1 6. Painon motion . «oo... 6. | @o) 1 [] Negative 2 [] Positive Cervical Thoracic Low back Diffuse Uncertain 7 ElexiBh I; aes stu nn s 7. | 0) O @9 OO @s9) 0 es) O (250) O 8. Extension ....coueeas 8. | @s)'O (259 ' OI (259) + O @9 0 @s) 1 9. Right lateral bending 9. | (9) O @w'0O @20)' C0 Qe) OI @d) 10. Left lateral bending .... 10. @2)' 0 (0) ' OI @9)'0] (@o'] @)'O 11. Right rotation. ........ n | (29) ' @9' 0 @9) ' CO @)'O 2) O 12. Left rotation ......... 12. | @y)' 0 @y' 0 @9' OI @9' 0 @rp)' O M. STRAIGHT-LEG-RAISING TEST | ETE AD A | @ CON 23 Pos. ARE EN GE 2 | t [J Neg. 2[] Pos. 3. Increase — i a. On ankle (right leg) . . . 3a. ! 1[JYes 2[]No b. Dorsiflexion (Left leg) i 1[JYes 2[]No 1 p> N. OTHER SYSTEMS (#82) 1 [J No findings — Skip to O (Reticulo endothelial, G.l., etc.) 2 [J] Findings — Describe — Sample Number HSM-4285-4 (PAGE 6) REV. 11/71 70 > 0. BLOOD PRESSURE TIME SYSTOLIC DIASTOLIC I I 1. Recumbent, « « os « ss 0 oss 1 @) 1 [JAM @) — — — Gd 2.88INE csveennsnnenanns Zi TIT 2] P.M. @) et BRE | P. SUMMARY OF DIAGNOSTIC I 1 [J Normal; no abnormal findings py IMPRESSIONS i 2 [[] Abnormal; significant findings noted below J Severity Certainty ICD code 1. Cardiovascular ) Min. Mod. Sev. (0-9) I . Ml @:0 0 0 @e @-—- | . Ww ®o 0 so @— @®-—-- | I c i @®0 0 0 @— © —-- I | | 2. Musculoskeletal | a. 2a. 1d 2] 3d (Goo) — G0 : . I b. bi @10 2] 30 @ — 0) I : L@®0 0 nn @- D--- I I 3. Respiratory i a. 0, @O 0 0 @— @--- | : I ] J@O 0 0 @— @--- I | J L@®0 0 0 @ ®--- | 4. Other systems — Specify : Wl @0 0 0 @— @--- b. LW @0 0 0 @— @--- Ce ! @0O = LJ @) — DB ~ I | 5. ! ) W@2 0 0 @- @--- I b wi @ 0 0 sO MD — @_ _ 3 5 I I c. ! @O 0 a0 @— @——- 1 Name of physician Sample Number HSM-428-4 paoe 7 REV. 11/7 71 HSM-4258 Form Approved REV. 11/71 0O.M.B. No. 68-R| 184 ASSURANCE OF CONFIDENTIALITY DERARTMENT OF HEL TN! EDUSATIGN, Avo WELFARE All information which would permit HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION identification of the individual will NATIONAL CENTER FOR HEALTH STATISTICS be held strictly confidential, will be HEALTH AND NUTRITION EXAMINATION SURVEY used only by sons, i and will not be disclosed or released GONIOMETRY to others for any other purposes (22 FR 1687). Deck No. Examiner No. Recorder No. 261 i 1. ON STOMACH a. Extension of right hip .... Tat llr hile la 180 — 160 a b. Extension of 1€ft hip «ov vvveenneneenennnns b. | 180-160 le 2. ON BACK a. Extension of right knee ................ ee, 6 0 sn b. Flexion of right knee . . . «cv vv vv eevee b. 180 — 30 i ots Fs Co Flexion of Fight Rip. «eve vnevnenernennn.. c. | 180-55 raid d. Adduction of Fight hip ......eueueuunn.n.. d. | o ie e. Abduction of right hip cvs ens ssas sens sores e. 90 — 140 sn f. Extension of left knee ..... JE. wo. Fo 0 sins g. Flexion of left knee. .....vvveuenennnns ... g. | 180-30 os h. Flexion of lefthip ....... we a Say h. 180 — 55 sn i. Adduction of 1Eft hip «ovo venue ennneennns io | o = j. Abduction of left hip ......oovvveennn ; wv Po 90 — 140 oo 3. SITTING ON TABLE a. Internal rotation of right hip «o.oo vv vee nnnn 3a. 40 — 90 J b. External rotation of right hip ...........0... b. 90 — 140 Gm c. Internal rotation of lefthip . ....ccovv even ©, 90 — 140 fm: a! 5 d. External rotation of left hip. .... PEE d. 40 —- 90 —_ NOTES Sample Number 72 % Form Approved HSM425-9 0.M.B. No. 68-R| 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit a TL METAL ELT, Si panier identification of the individual wil HEALTH AND NUTRITION EXAMINATION SURVEY be held strictly confidential, will be used only by persons engaged in and for the purposes of the survey, RESPIRATORY FUNCTION TESTS 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? . . EEE EERE vals | 1] Yes 2 [J] No- Explain — | | | I | | | d B. SINGLE BREATH DIFFUSING CAPACITY I l. Inspired Cou. s ss ss mwmmmmus cwenenne Vo 100% I 2. Small spirometer temperature . . ..... sus 20 | ~ =s?C | 3a. Uncorrected barometric pressure . . ..... 3a. —_ — —. — mm. Hg. b. Barometer temperature ...... oo b. : —~ =~=2C | : TRIAL #1 TRIAL #2 TRIAL #3 i UM: is spnvsnnmvw v Wwe . | 4. Inspired helium. ....... 4 | els i + 5. Expired helium percent. . . . . occ vv ue. 5. — | i i 1 6. Expired Co meterreading . ........... 6. L@) — — 7. Breath holding time *cm ...... exnnses Tu —_— | 8. Volume inspired V.C. (ATPS) ml ....... 8. | (009) — — 9. Was test satisfactory? ...... ok oe 9. | (020) 1 [J Yes | | * From tracing — % inspiration point ) measured to onset of expiration | NOTES Sample Number 73 HSM-425-10 Form Approved REV. 11/71 0O.M.B. No. 68-R| 184 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE ASSURANCE OF CONFIDENTIALITY PUBLIC HEALTH SERVICE All information which would permit HEALTH SERVICES AND MENTAL HEALTH ADMINISTRATION identification of the individual will NATIONAL CENTER FOR HEALTH STATISTICS be held strictly confidential, will be HEALTH AND NUTRITION EXAMINATION SURVEY used only by persons engaged In and for the purposes of the survey, and will not be disclosed or released AUDIOMETRY to others for any other purposes (22 FR 1687). : Deck No. Audio No. Examiner No. 241 maa ee START HERE IF SAMPLE NO. EVEN AIR CONDUCTION - RIGHT EAR BONE CONDUCTION ~ LEFT EAR MASKING on R for B/C Hearing levels (L) — If tone heard in R but not in L, record and circle Retest R with [Frequency| peaari R — level in space; if tone not heard : earing level } i masking on L* (Hz) £ HL+30 ] HL +40 [HL +50 | PR orb, record 55+ (a) (b) (b) c) @) @) @) ®|@|® @ G G ® START HERE IF SAMPLE NO. ODD (c) (a) ®®|® ®®®®| / AIR CONDUCTION —- LEFT EAR BONE CONDUCTION ~ RIGHT EAR Retest L with masking on R* Frequency (Hz) Hearing level MASKING on L for B/C Hearing levels (R) — If tone heard HL + 30 ~ a) HL + 40 in L but not R, record and circle L — level in space; if tone not heard HL + 50 in L or R, record 55 + (c) (2) (b) ©B®®®® ?/0/0/0® Condition affecting test results (Check only one) 1 [J] None 2 [J Cold or sinusitis now 3 [J] 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 — Describe ** a * 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 Sample Number 74 HSM425-2 REV. 11/71 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 TB SKIN TEST Form Approved 0O.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). Name (Last, first, middle) Deck No. 221 Tuberculin administrator Date (Month, day, year) : td I 1. Site injected 1. | + [J] Volar forearm ! 2 [] Other 2, Millimeter induration : | a. PPD=S (L.A.) 2.1 _ | b. PPD-B (R.A.) b. | et ae | 3. Reader 3. i Month Day Year | 4. Date read 4. | Ce ee en fs 5. Where read? 5. | Od Home 2 [] Work 3 [[] Exam center J a Other NOTES Sample Number 75 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NATIONAL CENTER FOR HEALTH STATISTICS ROCKVILLE, MD. 20852 HEALTH AND NUTRITION EXAMINATION SURVEY REPORT OF PHYSICAL FINDINGS Dear Doctor: Recently the person named below was a sample person who voluntarily participated as an examinee in the Health and Nutrition Examination Survey conducted at special facilities of the U.S. Public Health Service. The objectives of the Survey are to obtain information on the nutritional and general 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 (including an ophthalmologist and a dermatologist) 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. Sincerely, (ronetd Esl Arnold Engel, M.D. Medical Advisor Date of Age Height |Chest X-ray | EKG Nal inal] E xumies s examination " [7] Encl. [7] Encl. address Sox gh [1 Not done | [] Not done MEDICAL DERMATOLOGICAL OPHTHALMOLOGICAL VISUAL ACUITY [C] No new significant findings [C] No new significant findings [C1 No new significant findings I | | | | | | | | | | | | ‘ R Eye 0 /_ L Eye 20 hii [J] Without glasses [CJ With glasses [C] With contacts [C] Not tested Hematocrit vol % URINE Neg Tr 1 2 3 4 Hemoglobin mimes Albumin RBC count etiam ADL. OC Sugar WBC count thou /cc Ph [15 C16 C17 [08 C19 Sed rate mm /hr Hematest [7] Pos [] Neg Tuberculin ~ Audiogram — Decibels Sample Number PDs ed 8 500] 1000 2000 | 4000 PPD-B mm Not read Io ] SEE REVERSE SIDE FOR NOTES ON TESTS AND PROCEDURES 76 Medical Examination X Rays and EKG NOTES ON TESTS AND PROCEDURES tonometry on examinees age 20 and over. 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 — — HANES interpretations will be made later and used only as survey data. Hematology — Screening limits * - A physician, adermatologist, an ophthalmogist, and a dentist examined each examinee. The physician’s examination included the head and neck, chest (cardiopulmonary), abdomen, and extremities (musculo- skeletal and neurological) ~ however, rectal, pelvic, and breast examinations were excluded. The dermotologist’s examination supplemented the physician’s skin examination. The ophthalmologist’s examination included visual acuity and refraction, slit lamp and ophthalmoscopic visualization, and Micro- Cyanmet- Coulter Coulter Wintrobe Determination hematocrit hemoglobin counter counter Sed Rate Vol. % Hgb Gm% RBC /cc WBC /cc mm /hr Adult Males 41 — 52 14.0 — 16.5 4.6 — 6.2 mill. 4.3 — 10 thou. 0-9 Adult Females 36 — 48 12.0 — 14.5 4.2 — 5.4 mill. 4.3 — 10 thou. 0-20 Pregnant Females 33-42 10.5 — 14.0 3.7 —- 4.9 mill. 5.0 — 12 thou. 0-30 Urinalysis Tuberculin Audiometry considered normal. ROUGH GUIDELINES FOR dB REPORT AT 500 — 2000 cps. 25 dB or less — Hearing normal or more acute Clinical Chemistry — 30 - 40 dB 45 - 55 dB 60 - 70 dB - Dip and read method using Ames Hema-Combistix. - Near normal (difficulty with faint speech) - Mild (difficulty with normal speech) ~ Moderate (difficulty with loud speech) 75 - 100 dB - Severe (hears only amplified speech) 105 or more Laboratory test on blood and urine 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. - The skin test results are reported in mm. of induration observed 48 — 72 hours after the intradermal injections of (1) 5 tuberculin units (intermediate strength) of PPD-S and (2) 5 units of PPD-B (Battey strain antigen). For PPD-S, O—4 mm. is negative, 10 mm. or more is positive, and if PPD-S is greater than PPD-B, 5 — 9 mm. is positive. (If PPD-B is greater than PPD-S, 5 — 9 mm. is considered negative). - Air conduction readings are reported in decibels with respect to audiometric zero (ISO — 1964), which is — Profound (usually cannot understand amplified speech) * Results outside the screening limits are considered to warrant further investigation of the examinee BLOOD Test Result Screening limits * Test Result Screening limits * Vitamin A (P) —ug% 20 - 100 ug % Total bilirubin (S) gD 0.2-1.0mg% Iron (S) — ug % 40 — 200 ug % SGOT (S) —— units 10 — 40 units I.B.C. (5) — ug % 240 - 400 ug % | Alk. phos. (5) - . 30 - 80 LU. (SMA Folate (S) — mug % 5 — 30 mug% Uric acid (S) —mg% 25-70mg% Vitamin C (P) ——mg% 0.2 — 10.0 mg % Calcium (S) —mg% 90 -11.0mg% Total protein (S) ___gms% 5.0-85gms % Phosphrous (SorP) _mg% 25 -48mg% Albumin (S) gms % 3.0 ~55gns% | lodine (U) oh 50 ug or more Cholesterol _mg% 260 or less (P) = Plasma (S) = Serum (U) = Urine 77 ER Fre == - : nono I LF de FEE ont Co = =r a 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 veseavch,— 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 basedon 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 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 tothe 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 disciizrged patients in shori-stay hospitals, based on a sample of patient records in a national sampie of hospitals, Data on health resources: manpower and facililies,—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 divovce.—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, HSMHA Rockville, Md, 20852 DHEW Publication No. (HSM) 73-1310 Series 1-No. 10 b U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE Health Services and Mental Health Administration 5600 Fishers Lane Rockville, Maryland 20852 POSTAGE AND FEES PAID U.S. DEPARTMENT OF HEW HEW 396 OFFICIAL BUSINESS Penalty for Private Use $300 THIRD CLASS BLK. 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