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CDC OPTIONAL MODULES: Back
to topics
STATE LEVEL 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 excellent,very good,good
fair or poor?
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?
When
you are sick or need advice about your health,to which one of the
following places do you usually go?
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 medical care
but you could not get it?
What
is the main reason you could not get medical care?
FRUITS AND VEGETABLES Back
to topics
How
often do you drink fruit juices such as orange ,grapefruit or tomato?
Not
counting juice,how often do you eat fruit?
How
often do you eat green salad?
How
often do you eat potatoes not including french fries,fried potatoes
or potato chips?
How
often do you eat carrots?
Not counting carrots,potatoes ,or salad ,how many servings of vegetables
do you usually eat?
ASTHMA
Back
to topics
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?
FAMILY PLANNING Back to topics
Birth Control Use
Method of Birth Control
Reason for non-use
WEIGHT CONTROL Back
to topics
Are
you now trying to lose weight?
Are
you now trying to keep your current weight ,that is to keep from
gaining weight?
Are
you eating either fewer calories or less fat to lose weight or keep
from gaining weight?
Are
you using physical activity or exercise to lose weight?
In
the past 12 months,has a doctor,nurse or other health professional
given you advice about your weight?
WOMENS HEALTH Back
to topics
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 you had your last breast exam?
Have
you ever had a PAP smear?
How
long has it been since you had your last PAP smear?
Have
you had a hysterectomy?
OPTIONAL MODULE : DIABETES
Back
to topics
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 blood for glucose or sugar? Include
times when checked by a family member ,friend, or 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
to topics
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?
TOBACCO USE
Back
to topics
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
to topics
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?
As
far as you know ,have you ever been tested for HIV?
How
important do you think it is for people to know their HIV status
by getting tested?
Not
including blood donations,in what month and year was your last HIV
test?
What
was the main reason you had your test for HIV?
Where
did you have the HIV test in?
Please
tell me if any of the 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?
IMMUNIZATION Back
to topics
During
the past 12 months, have you had a flu shot?
At
what kind of place did you get your last flu shot?
Have
you ever had a pneumonia shot?
USE OF SEAT BELTS
Back
to topics
How
often do you use seat belts when you drive or ride in a car?
ALCOHOL CONSUMPTION Back
to topics
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?
Are
any of these firearms now loaded?
Are
any of these loaded firearms also unlocked?
OPTIONAL MODULE :PHYSICAL ACTIVITY
Back
to topics
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?
OPTIONAL MODULE: 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 your mental health was 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
OPTIONAL MODULE: CHILDHOOD ASTHMA Back
to topics
Earlier
you said there were [C12Q06] children age 17 or younger living in
your household.How many of these children have ever
been diagonised with Asthma?
Does
this child/How many of these children still have asthma?
PROSTATE CANCER SCREENING Back
to topics
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?
ORAL HEALTH Back
to topics
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?
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
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 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?
OPTIONAL MODULE : HYPERTENSION AWARENSS: Back
to topics
Are
you currently taking medicine for your high blood pressure?
Have
you ever been told by a doctor, nurse, or other health professional
that you have high blood pressure?
OPTIONAL MODULE :CHOLESTEROL AWARENESS Back
to topics
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
to topics
During the past 30 days, have you
had pain, aching, stiffness or swelling in or around a joint?
Did
your joint symptoms FIRST begin more than 3 months ago?
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 or other health professional that
you have some form of arthritis,rheumatoid arthritis,gout,lupus
or fibromyaglia?
Do
arthritis or joint symptoms now affect whether you work,the type
of work you do ,or the amount of work you do?
DOCTOR COST Back
to topics
Was
there a time during the past 12 months when you needed to see a
doctor, but could
not see because of the cost?
FLU COST
Back
to topics
Did
you receive a flu shot this year between January and May?
Did
you receive a flu shot last fall, or winter? (During Sep-Dec of
2001)
What
is the main reason you didn’t get a flu shot during the past
12 months?
Have
you ever had the Chicken Pox?
ORAL HEALTH
Back
to topics
Have
you ever had a test or examination for oral or mouth Cancer in which
the Doctor
or dentist pulls on your tongue, sometimes which gauze wrapped around
it, and feels
under the tongue and inside the cheeks?
When
did you have your most recent oral or Mouth cancer exam?
Who,
that is what type of medical care person, examined you when you
had your last
checkup for oral cancer?
Have
you ever used or tried any smokeless tobacco products such as chewing
tobacco
or snuff?
Do
you currently use chewing tobacco or snuff every day, some days
or not at all?
SENIORS
Back
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Sometimes people provide
care or assistance to others who are elderly, ill or disabled.
During the past 30 days, did you provide any type of care or assistance
to a friend or
relative who is 60 years or older?
Are
you aware of a senior center in your community?
Have
you ever participated in any activities provided by this senior
center?
During
the past 60 days how often did you have difficulty arranging for
transportation
to get to places you want or need to go?
Are
you limited in any activities because of physical, mental, memory
or emotional
problems?
Because
of any impairment or health problem, do you need someone to help
with your
PERSONAL CARE needs, such as eating, bathing, dressing or getting
around the house?
Who
usually helps you with your personal care needs, such as eating,
bathing, dressing,
or getting around the house?
Because
of any impairment or health problem, do you need someone to help
in
handling your ROUTINE needs, such as everyday household chores,
shopping or getting
around for other purposes?
RISK FACTORS: Back
to topics
Body Mass
Index Grouping-Underweight, Recommended Range, Overweight and Obese
Overweight
or Obese
Risk factor
for lifetime Asthma prevelance
Risk factor
for current Asthma prevelance
Risk
factor for having had permenant teeth extracted
Risk Factor
for respondents aged 65 or older that have had all permanent teeth
extracted
Risk Factor
for having visited a dentist, dental hygenist or dental clinic
Risk factor
for respondents aged 65+ that had a flu shot in the past 12 months
Risk factor
for respondents aged 65 or older that have ever had a pneumonia
shot
Smoking
Status
Current
Smoker
Worksites
prohibit smoking in both public and work areas
Drinking
alcohol in the past 30 days
Binge
Drinking
Heavy
Drinking
Risk
factor for drinking and driving
Risk
factor for always seatbelt use
Leisure
Time Physical Activity
History
of Any Cardiovascular Diseases
Fruit
and Vegetable Consumption per day
Female
respondents aged 40 and older that have not had a mammogram within
the past two years
Female
respondents aged 18 and older, with intact cervix, that have not
had a pap smear within the past three years
Male
respondents aged 40 and older that have not had a Prostate-Specific
Antigen test wtihin the past two years
Respondents
aged 50 and older that have not had a blood stool test within the
past two years
Respondents
aged 50 and older that have not had a sigmoidoscopy or colonoscopy
Respondents
less than 65 years old that have ever participated in high-risk
behavior
Risk
factor for having been counseled by a doctor, nurse, or other health
professional within the past 12 months on prevention
of sexually transmitted diseases through condom use
Risk
factor for living in home with loaded firearm
Risk
factor for living in home with loaded and unlocked firearm
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