(View in Courier New, 10 pt.) 1997 Behavioral Risk Factor Surveillance System Questionnaire Optional Modules Module 1: Diabetes 1. How old were you when you were told you have diabetes? (149-150) Code age in years [76=76 and older] __ __ Don't know/Not sure 7 7 Refused 9 9 2. Are you now taking insulin? (151) a. Yes 1 b. No Go to Q. 4 2 Refused Go to Q. 4 9 3. Currently, about how often do you use insulin? (152-154) a. Times per day 1 __ __ b. Times per week 2 __ __ c. Use insulin pump 3 3 3 Don't know/Not sure 7 7 7 Refused 9 9 9 4. 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. (155-157) a. Times per day 1 __ __ b. Times per week 2 __ __ c. Times per month 3 __ __ d. Times per year 4 __ __ e. Never 8 8 8 Don't know/Not sure 7 7 7 Refused 9 9 9 5. Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated HE-mo-glo-bin] or hemoglobin "A one C"? (158) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 6. About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes? (159-160) a. Number of times __ __ b. None Go to Q. 9 8 8 Don't know/Not sure Go to Q. 9 7 7 Refused Go to Q. 9 9 9 If "No," "Dk/Ns," or "Refused" to Q. 5, go to Q. 8. 7. About how many times in the last year has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A one C"? (161-162) a. Number of times __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 8. About how many times in the last year has a health professional checked your feet for any sores or irritations? (163-164) a. Number of times __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 9. 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. (165) Read Only if Necessary a. Within the past month (0 to 1 month ago) 1 b. Within the past year (1 to 12 months ago) 2 c. Within the past 2 years (1 to 2 years ago) 3 d. 2 or more years ago 4 e. Never 8 Don't know/Not sure 7 Refused 9 I would now like to ask you three questions about how well you see with your glasses or contacts on if you use them. 10. How much of the time does your vision limit you in recognizing people or objects across the street? (166) Would you say: Please Read a. All of the time 1 b. Most of the time 2 c. Some of the time 3 d. A little bit of the time 4 or e. None of the time 5 Do not Don't know/Not sure 7 read these responses Refused 9 11. How much of the time does your vision limit you in reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone? (167) Would you say: Please Read a. All of the time 1 b. Most of the time 2 c. Some of the time 3 d. A little bit of the time 4 or e. None of the time 5 Do not Don't know/Not sure 7 read these responses Refused 9 12. How much of the time does your vision limit you in watching television? (168) Would you say: Please Read a. All of the time 1 b. Most of the time 2 c. Some of the time 3 d. A little bit of the time 4 or e. None of the time 5 Do not Don't know/Not sure 7 read these responses Refused 9 Module 2: Sexual Behavior If respondent 50 years old or older, go to next module 1. During the past twelve months, with how many people have you had sexual intercourse? (169-170) a. Number __ __ b. None Go to Next Module 8 8 Don't know/Not sure 7 7 Refused 9 9 2. Was a condom used the last time you had sexual intercourse? (171) a. Yes 1 b. No Go to Q. 4 2 Don't know/Not sure Go to Q. 4 7 Refused Go to Q. 4 9 3. The last time you had sexual intercourse, was the condom used ... (172) Please Read a. To prevent pregnancy 1 b. To prevent diseases like syphilis, gonorrhea, and AIDS 2 c. For both of these reasons 3 or d. For some other reason 4 Do not Don't know/Not sure 7 read these responses Refused 9 4. 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? (173) Would you say: Please Read a. Very effective 1 b. Somewhat effective 2 or c. Not at all effective 3 Don't know how effective 4 Do not read these Don't know method 5 responses Refused 9 5. How many new sex partners did you have during the past twelve months? (174-175) A new sex partner is a. Number [76 = 76 or more] __ __ someone the respon- b. None 8 8 dent had sex with for the Don't know/Not sure 7 7 first time in the past 12 Refused 9 9 months 6. I'm going to read you a list. When I'm done, please tell me if any of the situations apply to you. You Don't need to tell me which one. 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 tested positive for having HIV, the virus that causes AIDS You had anal sex without a condom in the past year Do any of these situations apply to you? (176) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 7. In the past five years, have you been treated for a sexually transmitted or venereal disease? (177) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 8. Were you treated at a health department STD clinic? (178) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Module 3: Health Care Coverage If "Dk/Ns" or "Refused" to core Q. 5, go to next module. I asked you previously about your health care coverage. If "None" to core Q. 7a or core Q. 7b, continue. Otherwise, go to Q. 2. 1. What is the main reason you are without health care coverage? (179-180) Reason Code __ __ a. Lost job or changed employers Go to Next Module 0 1 b. Spouse or parent lost job or changed employers [includes any person who had been providing insurance prior to job loss or change] Go to Next Module 0 2 c. Became divorced or separated Go to Next Module 0 3 d. Spouse or parent died Go to Next Module 0 4 e. Became ineligible because of age or because left school Go to Next Module 0 5 f. Employer doesn't offer or stopped offering coverage Go to Next Module 0 6 g. Cut back to part time or became temporary employee Go to Next Module 0 7 h. Benefits from employer or former employer ran out Go to Next Module 0 8 i. Couldn't afford to pay the premiums Go to Next Module 0 9 j. Insurance company refused coverage Go to Next Module 1 0 k. Lost Medicaid or Medical Assistance eligibility Go to Next Module 1 1 l. Other Go to Next Module 8 7 Don't know/Not sure Go to Next Module 7 7 Refused Go to Next Module 9 9 2. Other than [fill in type (Medicare/Medicaid/the health coverage which pays for most of your medical care) from core Q. 6, Q. 7a, or Q. 7b], do you have any other type of health care coverage? (181) Do not include a. Yes 1 plans that only cover b. No 2 one type of service or Don't know/Not sure 7 care Refused 9 If respondent 66 years old or older, go to next module. 3. During the past 12 months, was there any time that you did not have any health insurance or coverage? (182) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 4. What was the main reason you were without health care coverage? (183-184) Reason Code __ __ a. Lost job or changed employers 0 1 b. Spouse or parent lost job or changed employers [includes any person who had been providing insurance prior to job loss or change] 0 2 c. Became divorced or separated 0 3 d. Spouse or parent died 0 4 e. Became ineligible because of age or because left school 0 5 f. Employer doesn't offer or stopped offering coverage 0 6 g. Cut back to part time or became temporary employee 0 7 h. Benefits from employer or former employer ran out 0 8 i. Couldn't afford to pay the premiums 0 9 j. Insurance company refused coverage 1 0 k. Lost Medicaid or Medical Assistance eligibility 1 1 l. Other 8 7 Don't know/Not sure 7 7 Refused 9 9 Module 4: Health Care Utilization Now I am going to ask you some questions about the health care you receive. 1. How would you rate your satisfaction with your overall health care? (185) Would you say: Please Read a. Excellent 1 b. Very Good 2 c. Good 3 d. Fair 4 or e. Poor 5 Do not Not applicable/don't use any health services 8 read these responses Don't know/Not sure 7 Refused 9 2. Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health? (186) a. Yes Go to Q. 5 1 b. More than one place Go to Q. 4 2 c. No 3 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 3. What is the main reason you do not have a usual source of medical care? (187-188) Reason Code __ __ a. Two or more usual places 0 1 b. Have not needed a doctor Go to Next Module 0 2 c. Do not like/trust/believe in doctors Go to Next Module 0 3 d. Do not know where to go Go to Next Module 0 4 e. Previous doctor is not available/moved Go to Next Module 0 5 f. No insurance/cannot afford Go to Next Module 0 6 g. Speak a different language Go to Next Module 0 7 h. No place is available/close enough/convenient Go to Next Module 0 8 i. Other Go to Next Module 0 9 Don't know/Not sure Go to Next Module 7 7 Refused Go to Next Module 9 9 4. Is there one of these places that you go to most often when you are sick or need advice about your health? (189) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 5. What kind of place is it -- a clinic, a health center, a hospital, a doctor's office, or some other place? (190-191) Facility Code __ __ a. Doctor's office or private clinic 0 1 b. Company or school health clinic/center 0 2 c. Community/migrant/rural clinic/center 0 3 d. County/city/public hospital outpatient clinic 0 4 e. Private/other hospital outpatient clinic 0 5 f. Hospital emergency room 0 6 g. HMO/prepaid group 0 7 h. Psychiatric hospital or clinic 0 8 i. VA hospital or clinic 0 9 j. Military health care facility 1 0 k. Some other kind of place 1 1 Don't know/Not sure 7 7 Refused 9 9 6. Thinking of the distance or time you travel to get to the place you usually go to, how would you rate the convenience of that place? (192) Would you say: Please Read a. Excellent 1 b. Very Good 2 c. Good 3 d. Fair 4 or e. Poor 5 Do not Don't have usual place 6 read these responses Don't know/Not sure 7 Refused 9 7. Is there one particular doctor or health professional who you usually go to when you need routine medical care? (193) If "no," ask a. Yes, only one 1 "Is there more than one or is b. More than one Go to Next Module 2 there no usual doctor who you c. No Go to Next Module 3 go to?" Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 8. When did you last change doctors? (194) Read only if necessary "Doctors" a. Within the past year (1 to 12 months ago) 1 includes other b. Within the past 2 years (1 to 2 years ago) 2 health profes- c. Within the past 3 years (2 to 3 years ago) 3 sionals d. Within the past 5 years (3 to 5 years ago) 4 e. 5 or more years ago 5 f. Never Go to Next Module 8 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 9. Why did you change doctors that last time? (195-196) Reason Code __ __ "Doctors" a. Changed residence or moved 0 1 includes other b. Changed jobs 0 2 health profes- c. Changed health care coverage 0 3 sionals d. Provider moved or retired 0 4 e. Dissatisfied with former provider or liked new provider better 0 5 f. Former provider no longer reimbursed by my health care coverage 0 6 g. Owed money to former provider 0 7 h. Medical care needs changed 0 8 i. Other 8 7 Don't know/Not sure 7 7 Refused 9 9 Module 5: Oral Health 1. How long has it been since you last visited the dentist or a dental clinic? (197) Read Only if Necessary a. Within the past year (1 to 12 months ago) Go to Q. 3 1 b. Within the past 2 years (1 to 2 years ago) 2 c. Within the past 5 years (2 to 5 years ago) 3 d. 5 or more years ago 4 Don't know/Not sure Go to Q. 3 7 Never 8 Refused Go to Q. 3 9 2. What is the main reason you have not visited the dentist in the last year? (198-199) Reason code __ __ Read only if necessary a. Fear, apprehension, nervousness, pain, dislike going 0 1 b. Cost 0 2 c. Do not have/know a dentist 0 3 d. Cannot get to the office/clinic (too far away, no transportation, no appointments available) 0 4 e. No reason to go (no problems, no teeth) 0 5 f. Other priorities 0 6 g. Have not thought of it 0 7 h. Other 0 8 Don't know/Not sure 7 7 Refused 9 9 3. 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. (200) a. 5 or fewer 1 b. 6 or more but not all 2 c. All 3 d. None 8 Don't know/Not sure 7 Refused 9 4. 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? (201) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Module 6: Preventive Counseling Services The next questions are about counseling services related to prevention that you might have received from a doctor, nurse, or other health professional. 1. Has a doctor or other health professional ever talked with you about your diet or eating habits? (202) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 2. Has a doctor or other health professional ever talked with you about physical activity or exercise? (203) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 3. (Has a doctor or other health professional ever talked with you) about injury prevention, such as safety belt use, helmet use, or smoke detectors? (204) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 4. (Has a doctor or other health professional ever talked with you) about drug abuse? (205) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 5. (Has a doctor or other health professional ever talked with you) about alcohol use? (206) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 If "No" to core Q. 26 or "Not at all" to core Q. 27, go to Q. 7 6. (Has a doctor or other health professional) ever advised you to quit smoking? (207) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 If respondent 65 years old or older, go to next module 7. (Has a doctor or other health professional) ever talked with you about your sexual practices, including family planning, sexually transmitted diseases, AIDS, or the use of condoms? (208) If yes, a. Yes, within the past 12 months ask "About (1 to 12 months ago) 1 how long ago was b. Yes, within the past 3 years (1 to 3 years ago) 2 it?" c. Yes, 3 or more years ago 3 d. No 4 Don't know/Not sure 7 Refused 9 Module 7: Cardiovascular Disease 1. To lower your risk of developing heart disease or stroke, has a doctor advised you to... Please Read Yes No Dk/Ns Ref a. Eat fewer high fat or high cholesterol foods 1 2 7 9 (209) b. Exercise more 1 2 7 9 (210) 2. To lower your risk of developing heart disease or stroke, are you? Please Read Yes No Dk/Ns Ref a. Eating fewer high fat or high cholesterol foods? 1 2 7 9 (211) b. Exercising more? 1 2 7 9 (212) 3. Has a doctor ever told you that you had any of the following? Please Read Yes No Dk/Ns Ref a. Heart attack or myocardial infarction 1 2 7 9 (213) b. Angina or coronary heart disease 1 2 7 9 (214) c. Stroke 1 2 7 9 (215) If respondent 35 years old or older continue with Q. 4. Otherwise, go to next module. 4. Do you take aspirin daily or every other day? (216) a. Yes Go to Q. 6 1 b. No 2 Don't know/Not sure 7 Refused 9 5. Do you have a health problem or condition that makes taking aspirin unsafe for you? (217) If yes, ask a. Yes, not stomach related Go to Q. 7 1 "Is this a stomach b. Yes, stomach problems Go to Q. 7 2 condition?" Code upset c. No Go to Q. 7 3 stomachs as stomach Don't know/Not sure Go to Q. 7 7 problems Refused Go to Q. 7 9 6. Why do you take aspirin? Please Read Yes No Dk/Ns Ref a. To relieve pain 1 2 7 9 (218) b. To reduce the chance of a heart attack 1 2 7 9 (219) c. To reduce the chance of a stroke 1 2 7 9 (220) If respondent is male or is female and pregnant, go to next module. The next few questions are about menopause, or what some women refer to as the "change of life." If "yes" to core Q. 59 or if respondent is age 65 or older, go to Q. 8. 7. Have you gone through or are you now going through menopause? (221) Probe a. Yes, have gone through menopause 1 for which b. Yes, now going through menopause 2 c. No Go to Next Module 3 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 8. Estrogens such as Premarin and progestins such as Provera are female hormones that may be prescribed around the time of menopause, after menopause, or after a hysterectomy. Has your doctor discussed the benefits and risks of estrogen with you? (222) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 9. Other than birth control pills, has your doctor ever prescribed estrogen pills for you? (223) Do not a. Yes 1 include estrogen b. No Go to Next Module 2 patches Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 10. Are you currently taking estrogen pills? (224) Do not a. Yes 1 include estrogen b. No 2 patches Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 11. Why... are you taking...[if "Yes" to Q. 10] did you take...[if "No" to Q. 10] ...estrogen pills? Never Please Read Yes No Dk/Ns took Ref a. To prevent a heart attack 1 2 7 8 9 (225) b. To treat or prevent bone thinning, bone loss, or osteoporosis 1 2 7 8 9 (226) c. To treat symptoms of menopause such as hot flashes 1 2 7 8 9 (227) Module 8: Arthritis 1. During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint? (228) a. Yes 1 b. No Go to Q. 4 2 Don't know/Not sure Go to Q. 4 7 Refused Go to Q. 4 9 2. Were these symptoms present on most days for at least one month? (229) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 3. Are you now limited in any way in any activities because of joint symptoms? (230) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 4. Have you ever been told by a doctor that you have arthritis? (231) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 5. What type of arthritis did the doctor say you have? (232-233) Type Code __ __ Read Only if Necessary a. Osteoarthritis/degenerative arthritis 0 1 b. Rheumatism 0 2 c. Rheumatoid Arthritis 0 3 d. Lyme disease 0 4 e. Other(specify) 0 7 f. Never saw a doctor 8 8 Don't know/Not sure 7 7 Refused 9 9 6. Are you currently being treated by a doctor for arthritis? (234) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Module 9: Quality of Life These next questions are about limitations you may have in your daily life. 1. Are you limited in any way in any activities because of any impairment or health problem? (235) a. Yes 1 b. No Go to Q. 6 2 Don't know/Not sure Go to Q. 6 7 Refused Go to Q. 6 9 2. What is the major impairment or health problem that limits your activities? (236-237) Reason Code __ __ a. Arthritis/rheumatism 0 1 b. Back or neck problem 0 2 c. Fractures, bone/joint injury 0 3 d. Walking problem 0 4 e. Lung/breathing problem 0 5 f. Hearing problem 0 6 g. Eye/vision problem 0 7 h. Heart problem 0 8 i. Stroke problem 0 9 j. Hypertension/high blood pressure 1 0 k. Diabetes 1 1 l. Cancer 1 2 m. Depression/anxiety/emotional problem 1 3 n. Other impairment/problem 1 4 Don't know/Not sure 7 7 Refused 9 9 3. For how long have your activities been limited because of your major impairment or health problem? (238-240) a. Days 1 __ __ b. Weeks 2 __ __ c. Months 3 __ __ d. Years 4 __ __ Don't know/Not Sure 7 7 7 Refused 9 9 9 4. Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house? (241) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 5. Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes? (242) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 6. 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? (243-244) a. Number of days __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 7. During the past 30 days, for about how many days have you felt sad, blue, or depressed? (245-246) a. Number of days __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 8. During the past 30 days, for about how many days have you felt worried, tense, or anxious? (247-248) a. Number of days __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 9. During the past 30 days, for about how many days have you felt you did not get enough rest or sleep? (249-250) a. Number of days __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 10. During the past 30 days, for about how many days have you felt very healthy and full of energy? (251-252) a. Number of days __ __ b. None 8 8 Don't know/Not sure 7 7 Refused 9 9 Module 10: Fruits and Vegetables These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and away from home. 1. How often do you drink fruit juices such as orange, grapefruit, or tomato? (253-255) a. Per day 1 __ __ b. Per week 2 __ __ c. Per month 3 __ __ d. Per year 4 __ __ e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 2. Not counting juice, how often do you eat fruit? (256-258) a. Per day 1 __ __ b. Per week 2 __ __ c. Per month 3 __ __ d. Per year 4 __ __ e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 3. How often do you eat green salad? (259-261) a. Per day 1 __ __ b. Per week 2 __ __ c. Per month 3 __ __ d. Per year 4 __ __ e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 4. How often do you eat potatoes not including french fries, fried potatoes, or potato chips? (262-264) a. Per day 1 __ __ b. Per week 2 __ __ c. Per month 3 __ __ d. Per year 4 __ __ e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 5. How often do you eat carrots? (265-267) a. Per day 1 __ __ b. Per week 2 __ __ c. Per month 3 __ __ d. Per year 4 __ __ e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 6. Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? (268-270) Example: a. Per day 1 __ __ A serving of vegetables b. Per week 2 __ __ at both lunch and c. Per month 3 __ __ dinner would be two d. Per year 4 __ __ servings e. Never 5 5 5 Don't know/Not sure 7 7 7 Refused 9 9 9 Module 11: Exercise The next few questions are about exercise, recreation, or physical activities other than your regular job duties. 1. During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? (271) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 2. What type of physical activity or exercise did you spend the most time doing during the past month? (272-273) Activity (specify): __ __ See coding list A Refused Go to Q. 6 9 9 Ask Q. 3 only if answer to Q. 2 is running, jogging, walking, or swimming. All others, go to Q. 4. 3. How far did you usually walk/run/jog/swim? (274-276) See coding Miles and tenths __ __.__ list B if response is Don't know/Not sure 7 7 7 not in miles and tenths Refused 9 9 9 4. How many times per week or per month did you take part in this activity during the past month? (277-279) a. Times per week 1 __ __ b. Times per month 2 __ __ Don't know/Not sure 7 7 7 Refused 9 9 9 5. And when you took part in this activity, for how many minutes or hours did you usually keep at it? (280-282) Hours and minutes __:__ __ Don't know/Not sure 7 7 7 Refused 9 9 9 6. Was there another physical activity or exercise that you participated in during the last month? (283) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 7. What other type of physical activity gave you the next most exercise during the past month? (284-285) Activity (specify): See coding list A __ __ Refused Go to Next Module 9 9 Ask Q. 8 only if answer to Q. 7 is running, jogging, walking, or swimming. All others go to Q. 9. 8. How far did you usually walk/run/jog/swim? (286-288) See coding Miles and tenths __ __.__ list B if response is Don't know/Not sure 7 7 7 not in miles and tenths Refused 9 9 9 9. How many times per week or per month did you take part in this activity? (289-291) a. Times per week 1 __ __ b. Times per month 2 __ __ Don't know/Not sure 7 7 7 Refused 9 9 9 10. And when you took part in this activity, for how many minutes or hours did you usually keep at it? (292-294) Hours and minutes __:__ __ Don't know/Not sure 7 7 7 Refused 9 9 9 Activity List for Common Leisure Activities Coding List A Code Description 01. Aerobics class 02. Backpacking 03. Badminton 04. Basketball 05. Bicycling for pleasure 06. Boating (canoeing, rowing, sailing for pleasure or camping) 07. Bowling 08. Boxing 09. Calisthenics 10. Canoeing/rowing - in competition 11. Carpentry 12. Dancing-aerobics/ballet 13. Fishing from river bank or boat 14. Gardening (spading, weeding, digging, filling) 15. Golf 16. Handball 17. Health club exercise 18. Hiking - cross-country 19. Home exercise 20. Horseback riding 21. Hunting large game - deer, elk 22. Jogging 23. Judo/karate 24. Mountain climbing 25. Mowing lawn 26. Paddleball 27. Painting/papering house 28. Racketball 29. Raking lawn 30. Running 31. Rope skipping 32. Scuba diving 33. Skating - ice or roller 34. Sledding, tobogganing 35. Snorkeling 36. Snowshoeing 37. Snow shoveling by hand 38. Snow blowing 39. Snow skiing 40. Soccer 41. Softball 42. Squash 43. Stair climbing 44. Stream fishing in waders 45. Surfing 46. Swimming laps 47. Table tennis 48. Tennis 49. Touch football 50. Volleyball 51. Walking 52. Waterskiing 53. Weight lifting 54. Other______________ 55. Bicycling machine exercise 56. Rowing machine exercise Coding List B Lap Swimming Size pool/Laps 50 ft. pool: 10 laps = .1 mile 100 ft. pool: 5 laps = .1 mile 50 meter pool: 3 laps = .1 mile Running/Jogging/Walking 1/2 mile = .5 mile 1/4 mile = .3 mile 1/8 mile = .1 mile 1 block = .1 mile Module 12: Weight Control 1. Are you now trying to lose weight? (295) a. Yes Go to Q. 3 1 b. No 2 Don't know/Not sure 7 Refused 9 2. Are you now trying to maintain your current weight, that is to keep from gaining weight? (296) a. Yes 1 b. No Go to Q. 6 2 Don't know/Not sure Go to Q. 6 7 Refused Go to Q. 6 9 3. Are you eating either fewer calories or less fat to... lose weight? [if "Yes" on Q. 1] keep from gaining weight? [if "Yes" on Q. 2] (297) Probe a. Yes, fewer calories 1 for which b. Yes, less fat 2 c. Yes, fewer calories and less fat 3 d. No 4 Don't know/Not sure 7 Refused 9 4. Are you using physical activity or exercise to... lose weight? [if "Yes" on Q. 1] keep from gaining weight? [if "Yes" on Q. 2] (298) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 5. How much would you like to weigh? (299-301) Weight __ __ __ pounds Don't know/Not sure 7 7 7 Refused 9 9 9 6. In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight? (302) Probe a. Yes, lose weight 1 for which b. Yes, gain weight 2 c. Yes, maintain current weight 3 d. No 4 Don't know/Not sure 7 Refused 9 Module 13: Folic Acid 1. Do you currently take any vitamin pills or supplements? (303) Include a. Yes 1 liquid supple- b. No Go to Q. 5 2 ments Don't know/Not sure Go to Q. 5 7 Refused Go to Q. 5 9 2. Are any of these a multivitamin? (304) a. Yes Go to Q. 4 1 b. No 2 Don't know/Not sure 7 Refused 9 3. Do any of the vitamin pills or supplements you take contain folic acid? (305) a. Yes 1 b. No Go to Q. 5 2 Don't know/Not sure Go to Q. 5 7 Refused Go to Q. 5 9 4. How often do you take this vitamin pill or supplement? (306-308) a. Times per day 1 __ __ b. Times per week 2 __ __ c. Times per month 3 __ __ Don't know/Not sure 7 7 7 Refused 9 9 9 If respondent 45 years old or older, go to next module 5. Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for which one of the following reasons... (309) Please Read a. To make strong bones 1 b. To prevent birth defects 2 c. To prevent high blood pressure 3 or d. Some other reason 4 Do not Don't know/Not sure 7 read these responses Refused 9 Module 14: Firearms The next questions are about safety and firearms. Firearms include weapons such as pistols, shotguns, and rifles. In answering the questions, do not include BB guns, starter pistols, or guns that cannot fire. 1. 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. (310) a. Yes 1 b. No Go to Next Module 2 Don't know/Not sure Go to Next Module 7 Refused Go to Next Module 9 2. Are any of the firearms handguns, such as pistols or revolvers? (311) a. Yes 1 b. No Go to Q. 4 2 Don't know/Not sure 7 Refused 9 3. Are any of the firearms long guns, such as rifles or shotguns? (312) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 4. What is the main reason that there are firearms in or around your home? (313) Would you say for... Please Read a. Hunting or sport 1 b. Protection 2 c. Work 3 or d. Some other reason 4 Don't know/Not sure 7 Refused 9 5. Is there a firearm in or around your home that is now both loaded and unlocked? (314) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Read the following if "employed" or "self-employed" on core Q. 42. Otherwise, go directly to Q. 6. The next three questions are about using firearms. If you are a police officer or have another occupation that requires and authorizes you to use a firearm, do not include firearm-use associated with your job. 6. During the last 30 days, have you carried a loaded firearm on your person, outside of the home for protection against people? (315) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 7. During the last 30 days, have you driven or been a passenger in a motor vehicle in which you knew there was a loaded firearm? (316) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 8. During the last 12 months, have you confronted another person with a firearm, even if you did not fire it, to protect yourself, your property, or someone else? (317) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 9. In the past three years, have you attended a firearm safety workshop, class, or clinic? (318) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 10. Do any of the firearms kept in or around your home belong to you, personally? (319) a. Yes 1 b. No 2 Don't know/Not sure 7 Refused 9 Module 15: Social Context These next questions are about your daily life. 1. How safe from crime do you consider your neighborhood to be? (320) Would you say: Please Read a. Extremely safe 1 b. Quite safe 2 c. Slightly safe 3 d. Not at all safe 4 Don't know/Not sure 7 Refused 9 2. Do you own or rent your home? (321) a. Own 1 b. Rent 2 Refused 9 3. How long have you lived at your current address? (322) Read Only if Necessary a. Less than six months (1 to 6 months) 1 b. Less than one year (6 to 12 months) 2 c. Less than two years (1 to 2 years) 3 d. 2 or more years 4 Don't know/Not sure 7 Refused 9 4. How many close friends or relatives would help you with your emotional problems or feelings if you needed it? (323) a. 3 or more 1 b. 2 2 c. 1 3 d. None 4 Don't know/Not Sure 7 Refused 9 5. In the past 30 days, have you been concerned about having enough food for you or your family? (324) a. Yes 1 b. No 2 Don't know/Not Sure 7 Refused 9 Module 16: Smokeless Tobacco Use 1. Have you ever used or tried any smokeless tobacco products such as chewing tobacco or snuff? (325) Probe for a. Yes, chewing tobacco 1 chewing tobacco, b. Yes, snuff 2 snuff, or both c. Yes, both 3 d. No, neither Go to Closing Statement 4 Don't know/Not sure Go to Closing Statement 7 Refused Go to Closing Statement 9 2. Do you currently use any smokeless tobacco products such as chewing tobacco or snuff? (326) "Yes" a. Yes, chewing tobacco 1 includes occa- b. Yes, snuff 2 sional use c. Yes, both 3 d. No, neither 4 Don't know/Not sure 7 Refused 9