1. Health Status1
Would you say that your health is:
1 Excellent
2 Very Good
3 Good
4 Fair or
5 Poor
6 DK/ Not sure
7 Refused

2. Health Status2
Now thinking about your physical health, which includes physical illness and injury, how many days during the last 30 days was your physical health not good?

3. Health Status3
Now thinking about your mental health, which includes physical stress, depression, and problems with emotions, how many days during the past 30 days was your mental health not good?

4. Health Status4
During the past 30 days, about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation?

5. Health Coverage1
Do you have any kind of health coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
1 Yes
2 No
3 DK/ Not sure
4 Refused

6. Health Coverage2
About how long has it been since you had health coverage?
(Read only if necessary)
1 1 to 6 months ago
2 6 to 12 months ago
3 1 to 2 years ago
4 2 to 5 years ago
5 5 or more years ago
6 DK/ Not sure
7 Refusal

7. Health Coverage3
Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
1 Yes
2 No
3 DK/ Not sure
4 Refusal

8. Health Coverage4
About how long has it been since you last visited a doctor for a routine checkup?
1 1 to 12 months ago
2 1 to 2 years ago
3 2 to 5 years ago
4 5 or more years ago
5 DK/ Not sure
6 Never
7 Refused

9. Hypertension1
Have you ever been told by a doctor, nurse, or other health professional that you have high blood pressure?
1 Yes
2 No
3 DK/ Not sure
4 Refused

10. Hypertension2
Have you ever been told by a doctor, nurse, or other health professional that your blood cholesterol is high?
1 Yes
2 No
3 DK/ Not sure
4 Refused

11. Diabetes
Have you ever been told by your doctor that you have diabetes?
If female answers yes, ask, "Was this only when you were pregnant?'
1 Yes
2 Yes, but female only during pregnancy
3 No
4 DK/ Not sure
5 Refused

12. Injury1
How often do you use seatbelts when you drive or ride in a car? Would you say…
1 Always
2 Nearly always
3 Sometimes,
4 Seldom, or
5 Never
6 DK/ Not sure
7 Never drive or ride in a car
8 Refused

13. Injury2
What is the age of the oldest child in your household under the age of 16?

14. Injury3
(For child under 5 years)
How often does this child use a safety seat when they ride in a car?
(For child 5 or older)
How often does this child use a seatbelt when they ride in a car?
Would you say . . .
1 Always
2 Nearly always
3 Sometimes,
4 Seldom, or
5 Never
6 DK/ Not sure
7 Never rides in a car
8 Refused

15. Injury4
When was the last time you or someone else deliberately tested all of the smoke detectors in your home, either pressing the test buttons or holding a source of smoke near them? (Read 1-5 only if necessary)
1 0 to 1 month ago
2 1 to 6 months ago
3 6 to 12 months ago
4 1 or more years ago
5 Never
6 No smoke detectors in house
7 DK/ Not sure
8 Refused

16. Tobacco1
Do you now smoke cigarettes everyday, some days, or not at all?
1 Everyday
2 Some days
3 Not at all
4 Refused

17. Tobacco2
Do you use any of the following tobacco products? (Choose all that apply)
1 Cigars
2 Pipes
3 Chewing tobacco or smokeless tobacco
4 None of the above

18. Tobacco3
Secondhand smoke is smoke exhaled by smokers and smoke that comes from the burning end of a cigarette, cigar, or pipe. During the past 30 days, have you been exposed to secondhand smoke?
1 Yes
2 No
3 DK/ Not sure
4 Refused

19. Tobacco4
In which settings are you exposed? (Choose all that apply)
1 Home
2 Work
3 Restaurant or
4 Other _____ _____
5 DK/ Not sure
6 Refused

20. Alcohol1
During the past month, have you had at least one drink of any alcoholic beverage such as beer, wine, wine coolers, or liquor?
1 Yes
2 No
3 DK/ Not sure
4 Refused

21. Alcohol2
Considering all types of alcoholic beverages, how many times during the last month did you have 5 or more drinks on an occasion?

22. Alcohol3
During the past month, how many times have you driven when perhaps you've had too much to drink?

23. Demo1
What is your age?

24. Demo2
What is your race? Would you say… (Please read 1-5)
1 White
2 Black
3 Asian, Pacific Islander
4 American Indian, Alaska Native, or
5 Other _____
6 DK/ Not sure
7 Refused

25. Demo3
Are you of Spanish or Hispanic origin?
1 Yes
2 No
3 DK/ Not sure
4 Refused

26. Demo4
Are you… (Please read 1-6)
1 Married
2 Divorced
3 Widowed
4 Separated
5 Never been married, or
6 A member of an unmarried couple
7 Refused

27. Demo5
How many children live in your household who are less than 5 years old?

28. Demo6
How many children live in your household who are 5 through 12 years old?

29. Demo7
How many children live in your household who are 13 through 17 years old?

30. Demo8
What is the highest grade or year of school you completed? (Read only if necessary)
1 Never attended school or only kindergarten
2 Grades 1 through 8 (Elementary)
3 Grades 9 through 12 (Some high school)
4 Grade 12 or GED (High school graduate)
5 College 1 to 3 years (Some college or technical school)
6 College 4 years or more (College graduate)
7 Refused

31. Demo9
Are you currently… (Please read 1-8)
1 Employed for wages
2 Self-employed
3 Out of work for more than 1 year
4 Out of work for less than 1 year
5 Homemaker
6 Student
7 Retired
8 Unable to work
9 Refused

32. Demo10
Is your household income from all sources..
1 Less than $25,000 If no ask 5, if yes ask 2
2 Less than $20,000 If no ask 1, if yes ask 3
3 Less than $15,000 If no code 2, if yes ask 4
4 Less than $10,000 If no code 3
5 Less than $35,000 If no ask 6
6 Less than $50,000 If no ask 7
7 Less than $75,000 If no code 8
8 $75,000 or more
9 DK/ Not sure
10 Refused

33. Demo11
About how much do you weigh without shoes?

34. Demo12
About how tall are you without shoes?

35. Demo13
Indicate sex of respondent (Do not ask)
1 Male
2 Female
3 DK/ Not sure

36. Female1
A mammogram is a x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
1 Yes
2 No
3 DK/ Not sure
4 Refused

37. Female2
How long has it been since you had a mammogram?
1 Within the past year
2 Within the past 2 years
3 Within the past 3 years
4 Within the past 5 years
5 5 or more years ago
6 DK/ Not sure
7 Refused

38. Female3
A clinical breast exam is when a doctor, nurse, or other health professional feels the breast for lumps. Have you ever had a clinical breast exam?
1 Yes
2 No
3 DK/ Not sure
4 Refused

39. Female4
A Pap Smear is a test for cancer of the cervix. Have you ever had a Pap Smear?
1 Yes
2 No
3 DK/ Not sure
4 Refused

40. Female5
Have you ever had a hysterectomy?
2 No
3 DK/ Not sure
4 Refused

43. Male1
A digital rectal exam is when a doctor or other health professional inserts a finger in the rectum to check for prostate cancer and other health problems. Have you ever had this exam?
1 Yes
2 No
3 DK/ Not sure
4 Refused

44. Male2
When did you have your last digital rectal exam?

45. Sexual Behavior1
The next few questions are about the national problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answer every question if you do not want to.
Due to what you know about HIV, have you changed your sexual behavior in the past 12 months?
1 Yes
2 No
3 DK/ Not sure
4 Refused

46. Sexual Behavior2
Did you make any of the following changes during the last 12 months?
Decrease the number of your sexual partners or become abstinent?
1 Yes
2 No
3 DK/ Not sure
4 Refused

47. Sexual Behavior3
Do you now always have sexual intercourse with only the same partner?
1 Yes
2 No
3 DK/ Not sure
4 Refused
5 Abstinent

48. Sexual Behavior4
Do you now always use condoms for protection?
1 Yes
2 No
3 DK/ Not sure
4 Refused
5 Abstinent

49. Oral Health1 How long has it been since you last visited the dentist or a dental clinic?
1 Within the past year
2 Within the past 2 years
3 Within the past 5 years
4 5 or more years ago
5 DK/ Not sure
6 Refused
7 Never

50. Oral Health2
What is the main reason you have not visited the dentist during the last year? (Select all that apply)
1 Fear, apprehension, pain, dislike going
2 Cost
3 Do not have/ know dentist
4 Cannot get to the office/ clinic (Too far away, etc)
5 No reason to go (No problems, no teeth)
6 Other priorities
7 Have not thought about it
8 Other _____
9 DK/ Not sure/ Refused

51. Counseling1
The next questions are about counseling services related to prevention you might have received from a doctor, nurse, or other health professional.
Has a doctor or other health professional ever talked with you about your diet or eating habits?
1 Yes
2 No
3 DK/ Not sure
4 Refused

52. Counseling2
Has a doctor or other health professional ever talked with you about physical activity or exercise?
1 Yes
2 No
3 DK/ Not sure
4 Refused

53. Counseling3
Has a doctor or other health professional ever talked with you about injury prevention, such as safety belts, helmet use, or smoke detectors?
1 Yes
2 No
3 DK/ Not sure
4 Refused

54. Counseling4
Has a doctor or other health professional ever talked with you about drug abuse?
1 Yes
2 No
3 DK/ Not sure
4 Refused

55. Counseling5
Has a doctor or other health professional ever talked with you about alcohol use?
1 Yes
2 No
3 DK/ Not sure
4 Refused

56. Counseling6
Has a doctor or health professional ever advised you to quit smoking?
1 Yes
2 No
3 DK/ Not sure
4 Refused

57. Counseling7
Has a doctor or health professional ever talked with you about your sexual practices, including family planning, sexually transmitted disease, AIDS, or the use of condoms?
1 Yes
2 No
3 DK/ Not sure
4 Refused

58. Counseling8
Has a doctor or other health professional ever talked with you about family violence?
1 Yes
2 No
3 DK/ Not sure
4 Refused

59. Cadiovascular1
To lower your risk of developing heart disease or stroke, has a doctor ever advised you to eat fewer high fat or high cholesterol foods?
1 Yes
2 No
3 DK/ Not sure
4 Refused

60. Cardiovascular2
Has a doctor advised you to exercise more?
1 Yes
2 No
3 DK/ Not sure
4 Refused

61. Cardiovascular3
To lower your risk of developing heart disease or stroke, are you eating fewer high fat or high cholesterol foods?
1 Yes
2 No
3 DK/ Not sure
4 Refused

62. Cardiovascular4
Are you exercising more?
1 Yes
2 No
3 DK/ Not sure
4 Refused

63. Cardiovascular5
Has a doctor told you that you have any of the following…
Heart attack or myocardial infarction?
1 Yes
2 No
3 DK/ Not sure
4 Refused

64. Cardiovascular6
Angina or Coronary heart disease?
1 Yes
2 No
3 DK/ Not sure
4 Refused

65. Cardiovascular7
Or a stroke?
1 Yes
2 No
3 DK/ Not sure
4 Refused

66. Exercise1
During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
1 Yes
2 No
3 DK/ Not sure
4 Refused

67. Exercise2
How many times per week or per month did you take part in this activity during the past month?

68. Exercise3
And when you took part in this activity, for how many minutes or hours did you usually keep it up?

69. Weight1
Are now trying to lose weight?
1 Yes
2 No
3 DK/ Not sure
4 Refused

70. Weight2
Are you eating either fewer calories or less fat to lose weight? (Probe for which answer exactly)
1 Yes, fewer calories
2 Yes, less fat
3 Yes, fewer calories and less fat
4 No
5 DK/ Not sure
6 Refused

71. Weight3
Are you eating either fewer calories or less fat to keep from gaining weight? (Probe for which answer exactly)
1 Yes, fewer calories
2 Yes, less fat
3 Yes, fewer calories and less fat
4 No
5 DK/ Not sure
6 Refused

72. Weight4
Are you using physical activity or exercise to lose weight?
1 Yes
2 No
3 DK/ Not sure
4 Refused

73. Weight5
Are you using physical activity or exercise to keep from gaining weight?
1 Yes
2 No
3 DK/ Not sure
4 Refused

74. Firearms1
Are any firearms now kept in or around your home? Includes those kept in your garage, outdoor storage, car, truck, or other motor vehicle.
1 Yes
2 No
3 DK/ Not sure
4 Refused

75. Firearms2
What is the main reason that there are firearms in and around your home? Would you say…
1 Hunting or sport
2 Protection
3 Work or
4 Some other reason __________
5 DK/ Not sure
6 Refused

76. Firearms3
During the last 30 days, have you carried a loaded firearm on your person, outside of the home for protection against people?
1 Yes
2 No
3 DK/ Not sure
4 Refused

77. Social Environment1
How safe from crime do you consider your neighborhood to be? Would you say…
(Please read 1-4)
1 Extremely safe
2 Quite safe
3 Slightly safe
4 Not at all safe
5 DK/ Not sure
6 Refused

78. Social Environment2
In the past 30 days, have you been concerned about having enough food for you or your family?
1 Yes
2 No
3 DK/ Not sure
4 Refused

79. Family Violence1
During the past 4 weeks, how often have problems in your household led to insulting, swearing, threatening, yelling, hitting, or pushing? (Please read 1-5)
1 None of the time
2 A little of the time
3 Some of the time
4 Most of the time
5 All of the time
6 DK/ Not sure
7 Refused

80. Family Violence2
Within the past year, have you been emotionally or physically abused by your partner or someone important in your life?
1 Yes
2 No
3 DK/ Not sure
4 Refused

81. Family Violence3
How many times?

82. Family Violence4
Within the last year, have you been hit, slapped, kicked, or physically hurt by someone?
1 Yes
2 No
3 DK/ Not sure
4 Refused

83. Family Violence5
How many times?

84. Family Violence6
Within the last year, has anyone forced you to have intercourse or engage in sexual activities you did not want to do?
1 Yes
2 No
3 DK/ Not sure
4 Refused

85. Family Violence7
How many times?

86. Family Violence8
Are you afraid of your partner or anyone else?
1 Yes
2 No
3 DK/ Not sure
4 Refused