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CDC OPTIONAL MODULES: Back to topics
STATE ADDED QUESTIONS:
Back to topics
RISK FACTORS AND DERIVED
VARIABLES (Located within the corresponding section)
CDC
CORE SECTIONS:
HEALTH STATUS
 Would you say in general that your
health is excellent, very good, good, fair or poor?
RISK FACTORS / CREATED VARIABLES
Risk factor for fair and poor
health
HEALTHY DAYS Back to topics
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 to topics
Do you have any kind
of health care coverage, including health insurance, prepaid plans
such as HMOS, or government plans such as Medicare?
Do you have one person
you think of as your personal doctor or health care provider?
Was there a time in the
past 12 months when you needed to see a doctor but could not because
of cost?
EXERCISE
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During the past month,
other than your regular job, did you participate in any physical
activities or exercises such as running, calisthenics, golf, gardening,
or walking for exercise?
ENVIRONMENTAL FACTORS
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In the past 12 months
have you had an illness or symptoms that you think was caused by
something in the air inside a home, office, or other building?
In the past 12 months
have you had an illness or symptom that you think was caused by
pollution in the air outdoors?
EXCESS SUN EXPOSURE
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The next question is about
sunburns including anytime that even a small part of your skin was
red for more than 12 hours. Have you had a sunburn within the past
12 months?
Including times when even
a small part of your skin was red for more than 12 hours, how many
sunburns have you had within the past 12 months?
TOBACCO USE Back to topics
Have you smoked at least
100 cigarettes in your entire life?
Do you know smoke cigarettes
every day, some days or not at all?
During the past 12 months,
have you stopped smoking for one day or longer because you were
trying to quit smoking?
RISK FACTORS / CREATED VARIABLES
Four level computed smoking
status
Risk factor for smoking
ALCOHOL CONSUMPTION Back to topics
During the past 30 days,
how many days per week or per month did you have at least one drink
of any alcoholic beverage?
On 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?
During the past 30 days,
how many times have you driven when you’ve had perhaps too
much to drink?
RISK FACTORS / CREATED VARIABLES
Risk factor for respondents
having had at least one drink of alcohol in the past 30 days.
At risk for binge drinking.
Alcoholic Beverages Consumed
per Month.
At risk for heavy alcohol
consumption
Heavy Drinking Among Men
Heavy Drinking Among Women
ASTHMA Back to topics
Have you ever been told
by a doctor, nurse or other health professional that you had asthma?
Do you still have asthma?
RISK FACTORS / CREATED VARIABLES
Asthma status
DIABETES
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Have you ever been told
by a doctor that you have diabetes?
ORAL HEALTH
Back to topics
How long has it been
since you last visited a dentist or dental clinic for any reason?
How many of your permanent
teeth have been removed because of tooth decay or gum disease? Do
not include teeth lost for other reasons, such as injury or orthodontics.
Include teeth lost due to infection.
How long has it been
since you had your teeth cleaned by a dentist or dental hygienist?
RISK FACTORS / CREATED VARIABLES
Risk factor for having had
permanent teeth extracted.
Risk factor for having all
permanent teeth extracted.
Risk factor for having visited
a dentist, dental hygienist or dental clinic in the past year
IMMUNIZATION
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During the past 12 months,
have you had a flu shot?
During the past 12 months,
have you had a flu vaccine that was sprayed into your nose?
Have you ever had a pneumonia
shot? This shot is usually given only once or twice in a person’s
lifetime and is different from the flu shot. It is also called the
pneumocoocal vaccine.
RISK FACTORS / CREATED VARIABLES
Risk factor for respondents
aged 65 or older that did not have a flu shot within the past 12
months.
Risk factor for respondents
aged 65 or older that have never had a pneumonia shot.
VETERAN STATUS
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Have you ever served on
active duty in the United State Armed Forces, either in the regular
military or in a National Guard or Military Reserve Unit?
Which of the following
best describes your service in the United States Military?
In the last 12 months have
you received some or all of your health care from VA facilities?
WOMEN'S HEALTH
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Have you ever had a mammogram?
How long has it been since
you had your last mammogram?
Have you ever had a clinical
breast exam?
How long has it been
since your last breast exam?
Have you ever had a pap
test?
How long has it been
since you had your last pap test?
Have you had a hysterectomy?
RISK FACTORS / CREATED VARIABLES
Risk factor for women over
40 years of age that have not had a mammogram in the past two years.
Risk factor for women 18
years and older that have not had a pap test in the past three years.
PROSTATE CANCER SCREENING
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Have you ever had a PSA
test?
How long has it been since
you had your last PSA test?
Have you ever had a digital
rectal exam?
How long has it been since
your last digital rectal exam?
Have you ever been told
by a doctor, nurse or other health professional that you had prostate
cancer?
RISK FACTORS / CREATED VARIABLES
Risk factor for male respondents
over 40 years of age that have not had a PSA in the past 2 years.
COLORECTAL CANCER SCREENING
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A blood stool test is
a test that may use a special kit at home to determine whether the
stool contains blood. Have you ever had this 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 into the rectum to view the
colon 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?
RISK FACTORS / CREATED VARIABLES
Risk factor for respondents
over 50 years of age that have not had a blood stool test within
the past two years.
Risk factor for respondents
over 50 years of age that have never had a sigmoidoscopy or colonoscopy.
FAMILY PLANNING
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How do you feel about
having a child sometime in the future?
How soon would you want
to have a child?
RISK FACTORS / CREATED VARIABLES
Birth control use to
prevent pregnancy among male respondents aged 18-59 and females
aged 18-44.
Birth Control method
type for all men and women of reproductive age.
Main reason for non-use
of family planning among men and women at risk of pregnancy.
DISABILITY
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Are you limited in any
way in any activities because of physical, mental, or emotional
problems?
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? Include occasional
use or use in certain circumstances.
RISK FACTORS / CREATED VARIABLES
Created variable for
disability status
HIV/AIDS
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I am going to read two
statements about HIV, the virus that causes AIDS. After I read each
one, please tell me whether you think it is true or false, or if
you do not know. A pregnant woman with HIV can get treatment to
help reduce the chances that she will pass the virus on to her baby.
I am going to read two
statements about HIV, the virus that causes AIDS. After I read each
one, please tell me whether you think it is true or false, or if
you do not know. There are medical treatments available that are
intended to help a person who is infected with HIV to live longer.
Have you ever been tested
for HIV? Do not count tests you may have had as part of a blood
donation.
In the past 12 months,
how many times have you been tested for HIV, including times you
did not get your results?
Not including blood donations,
in what month and year was your last HIV test? Include saliva tests.
I am going to read you
a list of reasons why some people have been tested for HIV. No including
blood donations, which of these would you say was the main reason
for your last HIV test?
Where did you have your
last HIV test- at a private doctor or HMO office, at a counseling
and testing site, at a hospital, at a clinic, in a jail or prison,
at home or somewhere else?
What type of clinic
did you go to for your last HIV test?
Was this test done by
a nurse or other health worker, or with a home testing kit?
I am going to read you
a list. When I am done, please tell me if any of the situations
apply to you.: You have used intravenous drugs in the past year.
You have been treated for a sexually transmitted or venereal disease
in the past year. You have given or received money or drugs in exchange
for sex in the past year. You had anal sex without a condom in the
past year. Do any of these situations apply to you?
In the past 12 months
has a doctor, nurse or other health professional talked to you about
preventing sexually transmitted diseases through condom use?
FIREARMS
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Are any firearms kept
in or around your home?
Are any of these firearms
now loaded?
Are any of these loaded
firearms also unlocked?
RISK FACTORS / CREATED VARIABLES
Risk factor for respondents
living in a home with a loaded firearm.
Risk factor for respondents
living in a home with a loaded and unlocked firearm.
RISK FACTOR / CREATED VARIABLES
FOR OBESITY
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Four categories of Body Mass
Index
Risk factor for overweight
or obese
CDC OPTIONAL MODULES
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DIABETES
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 ever had any
sores or irritations on your feet that took more than four weeks
to heal?
About how many times
in the last year have you seen a doctor, nurse, or other health
professional for your diabetes?
A test for "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?
HEALTHY DAYS Back to topics
During the past 30 days,
for about how many days did pain make it hard for you to do your
usual activities, such as self-care, work or recreation?
During the past 30 days,
for about how many days have you felt sad, blue or depressed?
During the past 30 days,
for about how many days have you felt worried, tense or anxious?
During the past 30 days,
for about how many days have you felt you did not get enough rest
or sleep?
During the past 30 days,
for about how many days have you felt very healthy and full of energy?
CARDIOVASCULAR DISEASE Back to topics
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 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 any of the
following? A heart attack, also called a myocardial infraction.
Has a doctor, nurse or
other health professional ever told you that you had any of the
following? Angina or coronary heart disease.
Has a doctor, nurse or
other health professional ever told you that you had any of the
following? A stroke.
History of any cardiovascular
diseases (heart attack or coronary heart disease or stroke)
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 (heart attack or stroke) did you go to any kind of
outpatient rehabilitation? This is sometimes called “Rehab.”
Do you take aspirin daily
or every other day?
Do you have a health
problem or condition that makes taking aspirin unsafe for you?
Why do you take aspirin…to
relieve pain?
Why do you take aspirin…to
reduce the chance of a heart attack?
Why do you take aspirin…to
reduce the chance of a stroke?
SMOKING CESSATION Back to topics
About how long has it
been since you last smoked cigarettes regularly?
In the last 12 months,
how many times have you seen a doctor, nurse or other health professional
to get any kind of care for yourself?
In the last 12 months,
on how many visits were you advised to quit smoking by a doctor
or other health provider?
On how many visits did your
doctor, nurse or other health professional recommend to discuss
medication to assist you with quitting smoking, such as nicotine
gum, patch, nasal spray, inhaler, lozenge, or prescription medication
such as Wellbutrin/ Zyban/ Bupropion?
On how many visits did your
doctor or health provider recommend or discuss methods and strategies
other than medication to assist you with quitting smoking?
ARTHRITIS BURDEN Back to topics
The next questions refer
to your joints. Please do not include the back or neck. During the
past 30 days, have you had any symptoms of pain, aching or stiffness
in or around a joint?
Did your joint symptoms
fist begin more than 3 months ago?
Have you ever seen a
doctor or other health professional for these joint symptoms?
Have you ever been told
by a doctor or other health professional that you have some form
of arthritis, rheumatoid arthritis, gout, lupus or fibromyalgia?
Are you limited in any
way in any of your usual activities because of arthritis or joint
symptoms?
In this next question,
we are referring to work for pay. Do arthritis or joint symptoms
now affect whether you work, the type or work you do or the amount
of work you do?
ARTHRITIS MANAGEMENT Back to topics
Thinking about your arthritis
or joint symptoms, which of the following best describes you today?
Has a doctor or other
health professional ever suggested losing weight to help with your
arthritis or joint symptoms?
Has a doctor or other
health professional ever suggested physical activity or exercise
to help your arthritis or joint symptoms?
Have you ever taken an
educational course or class to teach you how to manage problems
related to your arthritis or joint symptoms?
REACTIONS TO RACE Back to topics
How do other people
usually classify you in this country? Would you say White, Black
or African American, Hispanic or Latino, Asian, Native Hawaiian
or other Pacific Islander, American Indian or Alaska Native, Multiracial
or some other group?
How often do you think
about your race? Would you say:
Within the past 12 months
at work, do you feel you were treated worse than, the same as, or
better than, people of other races?
Within the past 12 months
when seeking health care, do you feel your experiences were worse
than, the same as, or better than for people of other races?
During the past 30 days,
have you felt emotionally upset, for example angry, sad, or frustrated,
as a result of how you were treated based on your race?
Within the past 30 days,
have you experience any physical symptoms, for example headache,
an upset stomach, tensing of your muscles, or a pounding heart,
as a result of how you were treated based on your race?
STATE ADDED QUESTIONS
Back to topics
PHYSICAL ACTIVITY Back to topics
When you are at work,
which of the following best describes what you do?
Now thinking about 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 some increase
in breathing or heart rate?
How many days of the
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 times, 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?
RISK FACTORS / CREATED VARIABLES
Moderate Physical Activity
Vigorous Physical Activity
Physical Activity Recommendation
Status
NEIGHBORHOOD
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Does your neighborhood
have any sidewalks?
For walking at night,
does your neighborhood have adequate street lighting?
For physical activity,
do you use any private or membership only recreation facilities?
Do you use walking trails,
parks, playgrounds, and sports fields for physical activity?
Do you use shopping malls
for physical activity and/or walking programs?
SMOKING CESSATION
Back to topics
In the past 12 months,
did you do any of the following to help you stop smoking? Called
a help line or quit line?
PHYSICAL AND SEXUALVIOLENCE
Back to topics
Within the past year,
on any occasion were you hit, slapped, kicked, raped or otherwise
physically hurt by a spouse, partner, ex-spouse or partner, boyfriend,
girlfriend or date?
On the most recent occasion,
where did the violence take place?
Has anyone ever had sex
with you against your will or without your consent? This would include
situations where verbal threats, coercion, physical force, or a
weapon was used or you were not able to give consent for some reason.
Has anyone ever attempted
to have sex with you against your will or without your consent,
but intercourse/penetration did not occur? Again, this would include
situations where verbal threats, coercion, physical force, or a
weapon was used, or you were not able to give consent for some reason.
In the past 12 months,has
anyone had or attempted to have sex with you against your will or
consent?
Did the most recent experience
involve someone you know or a stranger?
EPILEPSY AND SEIZURE Back to topics
Have you ever been told
by a doctor that you have a seizure disorder or epilepsy?
Are you currently taking
any medicine to control your seizure disorder or epilepsy?
How many seizures have
you had in the last three months?
In the past year, have
you seen a neurologist or epilepsy specialist for your epilepsy
or seizure disorder?
During the past 30 days,
to what extent has epilepsy or its treatment interfered with your
normal activities like working, school, or socializing with family
or friends?
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