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CDC OPTIONAL MODULES: Back
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STATE
ADDED QUESTIONS: Back
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RISK FACTORS AND DERIVED VARIABLES Back
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HEALTH STATUS
Would you say that in general your health is :
Now
thinking about your physical health ,which includes physical illness and injury,for
how many days during the past 30 days was your physical health
not good ?
Now
thinking about your mental health ,which includes stress depression ,and problems
with emotions,,for how many days during the past 30 days was your
mental health not good ?
During
the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self-care, work, or
recreation?
HEALTH CARE ACCESS Back
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Do
you have any kind of health care coverage, including health insurance, prepaid
plans such as HMOs, or government plans such as Medicare?
During
the past 12 months, was there any time that you did not have any health insurance
or coverage?
Do
yuou have one person you think of as your personal doctor or health care provider?
STATE
ADDED MODULE : HEALTH CARE ACCESS Back
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Was there a time during the last 12 months when you
needed to see a doctor, but could not because of the cost?
ASTHMA: Back
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Have
you ever been told by a doctor,nurse or health care provider that you have asthma?
Do
you still have asthma?
DIABETES
: Back
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Have
you ever been told by a doctor that you have diabetes?
OPTIONAL
MODULE : DIABETES Back
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How
old were you when you were told you have diabetes?
Are
you now taking insulin?
Are
you now taking diabetes pills?
About
how often do you check your blood for glucose or sugar? Include times when checked
by a family member or friend, but do not include times when checked
by a health professional.
About
how often do you check your feet for any sores or irritations? Include times when
checked by a family member or friend, but do not include times when
checked by a health professional
Have
you had any sores or irritations on your feet that took more than four weeks to
heal?
About
how many times in the past 12 months have you seen a doctor, nurse, or other health
professional for your diabetes?
A
test for hemoglobin "A one C" measures the average level of blood sugar
over the past three months. About how many times in the past 12 months
has a doctor, nurse, or other health professional checked you for hemoglobin
"A one C"?
About
how many times in the past 12 months has a health professional checked your feet
for any sores or irritations?
When
was the last time you had an eye exam in which the pupils were dilated? This would
have made you temporarily sensitive to bright light.
Has
a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
Have
you ever taken a course or class in how to manage your diabetes yourself?
EXERCISE: Back
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During
the past month, did you participate in any physical activities or exercises such
as running, calisthenics, golf, gardening, or walking for exercise?
TOBACCO
USE: Back
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Have you smoked at least 100 cigarettes in your entire life?
Do
you now smoke cigarettes everyday, some days, or not at all?
During
the past 12 months, have you quit smoking for 1 day or longer?
HIV/AIDS: Back
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A
pregnant woman with HIV can get treatment to help reduce the chances that she
will pass the virus to her baby?
There
are medical treatments available that are intended to help a person who is infected
with HIV to live longer?
How
effective do you think these treatments are helping persons with HIV to live longer?
How
important do you think it is for people to know their HIV status by getting tested?
Have
you ever been tested for HIV?
What
was the main reason you had your test for HIV?
Where did you have the HIV test in?
In
the past 12 months did a doctor,nurse or health professional talk to you about
preventing sexually transmitted diseases through condom use?
IMMUNIZATION: Back
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During
the past 12 months, have you had a flu shot?
STATE
ADDED: IMMUNIZATION: Back
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Have
you ever had a pneumonia vaccination?
ALCOHOL
CONSUMPTION: Back
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During
the past 30 days, how often have you had at least one drink of any alcoholic beverage?
On
the days when you drank, about how many drinks did you drink on the average?
Considering
all types of alcoholic beverages, how many times during the past 30 days did you
have 5 or more drinks on an occasion?
FIREARMS:
Back
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Are
any firearms now kept in or around your home? Include those kept in a garage,
outdoor storage area, car, truck, or other motor vehicle.
DISABILITY: Back
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Are
you limited in any way in any activities because of physical, mental, or emotional
problems?
STATE
ADDED : DISABILITY Back
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Are
you limited in the kind or amount of work you can do because of any impairment
or health problem?
Do you now have any health problem that requires you to use special equipment,
such as a cane, a wheelchair, a special bed, or a special telephone?
What
is the farthest distance you can walk with any special equipment or help from
others?
PHYSICAL
ACTIVITY: Back
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When
you are at work, which of the following best describes what you do?
Now,
thinking about the moderate physical activities you do in a usual week, do you
do moderate activities for at least 10 minutes at a time, such as
brisk walking, bicycling, vacuuming, gardening, or anything else that causes small
increases in breathing or heart rate?
How
many days per week do you do these moderate activities for at least 10 minutes
at a time?
On days when you do moderate activities for at least 10 minutes at a time, how
much total time per day do you spend doing these activities?
Now
thinking about the vigorous physical activities you do in a usual week, do you
do vigorous activities for at least 10 minutes at a time, such as
running, aerobics, heavy yard work, or anything else that causes large increases
in breathing or heart rate?
How
many days per week do you do these vigorous activities for at least 10 minutes
at a time?
On
days when you do vigorous activities for at least 10 minutes at a time, how much
total time per day do you spend doing these activities?
PROSTATE
CANCER SCREENING: Back
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Have
you ever had a PROSTATE SPECIFIC ANTIGEN test?
How
long has it been since you had your last PSA test?
Have you ever had a digital rectal exam?
Have
you ever been told by a doctor, nurse, or other health professional that you had
prostate cancer?
Has
your father, brother, son, or grandfather ever been told by a doctor, nurse, or
health professional that he had prostate cancer?
COLORECTAL
CANCER SCREENING: Back
to topics
Have
you ever had a blood stool test using a home kit?
How long has it been since you had your last blood stool test using a home kit?
Sigmoidoscopy
and colonoscopy are exams in which a tube is inserted in the rectum to view the
bowel for signs of cancer or other health problems. Have you ever
had either of these exams?
How
long has it been since you had your last sigmoidoscopy or colonoscopy?
OPTIONAL
MODULE: ORAL HEALTH: Back
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How
long has it been since you last visited a dentist or a dental clinic for any reason?
How
many of your permanent teeth have been removed because of tooth decay or gum disease?
How
long has it been since you had your teeth cleaned by a dentist or dental hygienist?
What
is the main reason you have not visited the dentist in the past year?
Do
you have any kind of insurance coverage that pays for some or all of your routine
dental care, including dental insurance, prepaid plans such as HMOs,
or government plans such as Medicaid?
OPTIONAL
MODULE:HEART ATTACK AND STROKE: Back
to topics
Do
you think pain or discomfort in the jaw, neck, or back are symptoms of a heart
attack?
Do
you think feeling weak, lightheaded, or faint are symptoms of a heart attack?
Do
you think chest pain or discomfort are symptoms of a heart attack?
Do
you think sudden trouble seeing in one or both eyes is a symptom of a heart attack?
Do
you think pain or discomfort in the arms or shoulder are symptoms of a heart attack?
Do
you think shortness of breath is a symptom of a heart attack?
Do
you think sudden confusion or trouble speaking are symptoms of a stroke?
Do
you think sudden numbness or weakness of face, arm, or leg, especially on one
side, are symptoms of a stroke?
Do
you think sudden trouble seeing in one or both eyes is a symptom of a stroke?
Do
you think sudden chest pain or discomfort are symptoms of a stroke?
Do
you think sudden trouble walking, dizziness, or loss of balance are symptoms of
a stroke?
Do
you think severe headache with no known cause is a symptom of a stroke?
If
you thought someone was having a heart attack or a stroke, what is the first thing
you would do?
OPTIONAL
MODULE: CARDIOVASCULAR DISEASE: Back
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To
lower your risk of developing heart disease or stroke, are you eating fewer high
fat or high cholesterol foods?
To
lower your risk of developing heart disease or stroke, are you eating more fruits
and vegetables?
To
lower your risk of developing heart disease or stroke, are you more physically
active?
Within
the past 12 months, has a doctor, nurse, or other health professional told you
to eat fewer high fat or high cholesterol foods?
Within
the past 12 months, has a doctor, nurse, or other health professional told you
to eat more fruits and vegetables?
Within
the past 12 months, has a doctor, nurse, or other health professional told you
to be more physically active?
Has
a doctor, nurse, or other health professional ever told you that you had a heart
attack, also called a myocardial infarction?
Has
a doctor, nurse, or other health professional ever told you that you had a Angina
or coronary heart disease?
At
what age did you have your first heart attack?
At
what age did you have your first stroke?
After
you left the hospital following your heeart attack/stroke did you go to any kind
of outpatient rehabilitation?
Do you take aspirin daily or every other day?
Do
you have a health problem or condition that makes taking aspirin unsafe for you?
Do
you take Aspirin to relieve pain?
Do
you take Aspirin to reduce the chance of a heart attack?
Do
you take Aspirin to reduce the chance of a stroke?
OPTIONAL
MODULE:TOBACCO INDICATORS
: Back
to topics
How
old were you the first time you smoked a cigarette, even one or two puffs?
How
old were you when you first started smoking cigarettes regularly?
About
how long has it been since you last smoked cigarettes regularly?
In
the past 12 months, have you seen a doctor, nurse, or other health professional
to get any kind of care for yourself?
In
the past 12 months, has a doctor, nurse, or other health professional advised
you to quit smoking?
Which
statement best describes the rules about smoking inside your home?
Worksites
prohibit smoking in both public and work areas.
Which
of the following best describes your place of work's official smoking policy for
indoor public or common areas, such as lobbies, rest rooms, and lunch
rooms?
Which
of the following best describes your place of work's official smoking policy for
work areas?
STATE
ADDED:SEXUAL BEHAVIOR Back
to topics
Was
a condom used the last time you had sexual intercourse?
The
last time you had sexual intercourse for what was the condom used ?
Some
people use condoms to keep from getting infected with HIV through sexual activity.
How effective do you think a properly used condom is for this purpose?
How
many new sex partners did you have during the past 12 months?
STATE
ADDED: HYPERTENSION AWARENSS: Back
to topics
Are
you currently taking medicine for your high blood pressure?
HYPERTENSION
AWARENESS:
Back to topics
Have
you ever been told by a doctor, nurse, or other health professional that you have
high blood pressure?
CHOLESTEROL
AWARENESS : Back
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Blood
cholesterol is a fatty substance found in the blood. Have you ever had your blood
cholesterol checked?
Have
you ever been told by a doctor, nurse, or other health professional that your
blood cholesterol is high?
About
how long has it been since you last had your blood cholesterol checked?
ARTHRITIS: Back
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During
the past 12 months, have you had pain, aching, stiffness or swelling in or around
a joint?
Were
these symptoms present on most days for at least one month?
Are
you now limited in any way in any activities because of joint symptoms?
Have you ever seen a doctor,nurse or health professional for these joint symptons?
Have
you ever been told by a doctor that you have arthritis?
Are you currently being treated by a doctor for arthritis?
RISK
FACTORS: Back
to topics
Body
Mass Index Grouping-Underweight, Recommended Range, Overweight and Obese
Overweight
or Obese
Cholesterol
check within the last five years
Smoking
Status
Current
Smoker
Worksites
prohibit smoking in both public and work areas
Drinking
alcohol in the past 30 days
Binge
Drinking
Heavy
Drinking
Moderate
Physical Activity
Vigorous
Physical Activity
Leisure
Time Physical Activity
Physical
Activity Recommendation Status
History
of Any Cardiovascular Diseases (heart attack or coronary heart disease or stroke)
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