CDC Core
Section 1: Health Status
1.1
Data Results 1.1 		Would you say that in general your health is:
  • Excellent
  • Very good
  • Good
  • Fair
  • Poor
    		•
    Crosstabulation Table:
    Percentage of Adults with Fair or Poor Self-Perceived Health Status
    1.2
    Data Results 1.2     		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?
    1.3
    Data Results 1.3     		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?
    Crosstabulation Tables:
    Frequent Mental Distress
    1.4
    Data Results 1.4
    		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?
     
    CDC Core
    Section 2: Health Care Access
    2.1
    Data Results 2.1     		Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare?
    Crosstabulation Tables:
    Percentage of Adults who Lack Health Care Coverage
    2.2
    Data Results 2.2     		Medicare is a coverage plan for people 65 or over and for certain disabled people. Do you have Medicare?
    2.3
    Data Results 2.3     		What type of health care coverage do you use to pay for most of your medical care?
    2.3a There are some types of coverage you may not have considered. Please tell me if you have any of the following:
    2.4
    Data Results 2.4     		During the past 12 months, was there any time that you did not have any health insurance or coverage?
    2.5
    Data Results 2.5     		About how long has it been since you had health care coverage?
    2.6
    Data Results 2.6     		Was there a time during the last 12 months when you needed to see a doctor, but could not because of the cost?
    2.7
    Data Results 2.7     		About how long has it been since you last visited a doctor for a routine checkup?
     
    CDC Core
    Section 3: Asthma
    3.1
    Data Results 3.1     		Did a doctor ever tell you that you had asthma?
    3.2
    Data Results 3.2     		Do you still have asthma?
    Crosstabulation Table:
    Percentage of Adults with Current Asthma
     
    CDC Core
    Section 4: Diabetes
    4.1
    Data Results 4.1     		Have you ever been told by a doctor that you have diabetes?
    Crosstabulation Table:
    Percentage of Adults with Diagnosed Diabetes
     
    Access to CDC Optional Diabetes Module or State-Added Diabetes Module
     
    CDC Core
    Section 5: Care Giving
    5.1
    Data Results 5.1     		There are situations where people provide regular care or assistance to a family member or friend who is elderly or has a long-term illness or disability. During the past month, did you provide any such care or assistance to a family member or friend who is 60 years of age or older?
    5.2
    Data Results 5.2     		Who would you call to arrange short or long-term care in the home for an elderly relative or friend who was no longer able to care for themselves?
     
    Access to State-Added Quality of Life & Care Giving Module
     
    CDC Core
    Section 6: Exercise
    Crosstabulation Table:
     
    Percentage of Adults Not Participating in Regular and Vigorous Physical Activity
    Percentage of Adults Not Participating in Any Physical Activity
    Percentage of Adults Not Participating in Regular and Sustained Physical Activity
    6.1
    Data Results 6.1     		During the past month, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
    6.2
    Data Results 6.2     		What type of physical activity or exercise did you spend the most time doing during the past month?
    6.3 How far did you usually walk/run/jog/swim?
    6.4
    Data Results 6.4     		How many times per week or per month did you take part in this activity during the past month?
    6.5
    Data Results 6.5     		And when you took part in this activity, for how many minutes or hours did you usually keep at it?
    6.6
    Data Results 6.6     		Was there another physical activity or exercise that you participated in during the last month?
    6.7
    Data Results 6.7     		What other type of physical activity gave you the next most exercise during the past month?
    6.8 How far did you usually walk/run/jog/swim?
    6.9
    Data Results 6.9     		How many times per week or per month did you take part in this activity?
    6.10
    Data Results 6.10     		And when you took part in this activity, for how many minutes or hours did you usually keep at it?
     
    CDC Core
    Section 7: Tobacco Use
    7.1
    Data Results 7.1     		Have you smoked at least 100 cigarettes in your entire life?
    7.2
    Data Results 7.2     		Do you now smoke cigarettes everyday, some days, or not at all?
    Crosstabulation Table:
    Percentage of Adults Who Currently Smoke Cigarettes
    7.3
    Data Results 7.3     		On the average, about how many cigarettes a day do you now smoke?
    7.3a
    Data Results 7.3a     		On the average, when you smoked during the past 30 days, about how many cigarettes did you smoke a day?
    7.4
    Data Results 7.4     		During the past 12 months, have you quit smoking for 1 day or longer?
    7.5
    Data Results 7.5     		About how long has it been since you last smoked cigarettes regularly, that is, daily?
     
    Access to State-Added Tobacco Cessation Module
     
    CDC Core
    Section 8: Fruits and Vegetables
    Crosstabulation Table:
    		 Percentage of Adults Who Reported Consuming Fruits and Vegetables Less Than 5 Times per Day
    8.1
    Data Results 8.1     		How often do you drink fruit juices such as orange, grapefruit, or tomato?
    8.2
    Data Results 8.2     		Not counting juice, how often do you eat fruit?
    8.3
    Data Results 8.3     		How often do you eat green salad?
    8.4
    Data Results 8.4     		How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
    8.5
    Data Results 8.5     		How often do you eat carrots?
    8.6
    Data Results 8.6     		Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?
     
    CDC Core
    Section 9: Weight Control
    9.1
    Data Results 9.1     		Are you now trying to lose weight?
    9.2
    Data Results 9.2     		Are you now trying to maintain your current weight, that is to keep from gaining weight?
    9.3
    Data Results 9.3

    Are you eating either fewer calories or less fat to...

    lose weight? [if "Yes" on Q. 9.1]

    keep from gaining weight? [if "Yes" on Q. 9.2]
    9.4
    Data Results 9.4     		Are you using physical activity or exercise to...

    lose weight? [if "Yes" on Q. 9.1]

    keep from gaining weight? [if "Yes" on Q. 9.2]
    9.5
    Data Results 9.5     		In the past 12 months, has a doctor, nurse, or other health professional given you advice about your weight?
     
    CDC Core
    Section 10: Demographics
    10.1
    Data Results 10.1     		What is your age?
    10.2
    Data Results 10.2     		What is your race?
    10.3
    Data Results 10.3     		Are you of Spanish or Hispanic origin?
    10.4
    Data Results 10.4     		Are you:
     
    • Married
    • Divorced
    • Widowed
    • Separated
    • Never been married
    • A member of an unmarried couple
    10.5a
    Data Results 10.5a     		How many children live in your household who are... a. less than 5 years old?
    10.5b
    Data Results 10.5b     		How many children live in your household who are... b. 5 through 12 years old?
    10.5c
    Data Results 10.5c     		How many children live in your household who are... c. 13 through 17 years old?
    10.6
    Data Results 10.6     		What is the highest grade or year of school you completed?
    10.7
    Data Results 10.7     		Are you currently:
     
    • Employed for wages
    • Self-employed
    • Out of work for more than 1 year
    • Out of work for less than 1 year
    • Homemaker
    • Student
    • Retired
    • Unable to work
    10.8
    Data Results 10.8
    Is your annual household income from all sources:
    • Less than $25,000 ($20,000 to less than $25,000)
    • Less than $20,000 ($15,000 to less than $20,000)
    • Less than $15,000 ($10,000 to less than $15,000)
    • Less than $10,000

      • or
    • Less than $35,000 ($25,000 to less than $35,000)
    • Less than $50,000 ($35,000 to less than $50,000)
    • Less than $75,000 ($50,000 to less than $75,000)
    • $75,000 or more
    10.9
    Data Results 10.9     		Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit?
    10.10
    Data Results 10.10     		Which of the following best describes your current military status?
    10.11
    Data Results 10.11     		In the last 12 months have you received some or all of your health care from VA facilities?
    10.12 About how much do you weigh without shoes?
    Crosstabulation Table:
    Percentage of Adults who are Overweight or Obese (BMI >= 25)
    Percentage of Adults who are Obese (BMI >=30)
    10.13 How much would you like to weigh?
    10.14 About how tall are you without shoes?
    10.15 What county do you live in?
    10.16
    Data Results 10.16     		Do you have more than one telephone number in your household?
    10.17
    Data Results 10.17     		How many residential telephone numbers do you have?
    10.18
    Data Results 10.18     		Indicate sex of respondent. Ask Only if Necessary
     
    CDC Core
    Section 11: Women's Health
    Crosstabulation Table:
    		 Percentage of Women Ages 40 Years and Older Who Reported They Had Never Had a Clinical Breast Exam and a Mammogram
    Percentage of Women Ages 50 Years and Older Who Reported They Had Not Had a Clinical Breast Exam and a Mammogram within the Preceding Two Years
    11.1
    Data Results 11.1     		A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had a mammogram?
    Crosstabulation Table:
    Percentage of Women Ages 40 Years and Older Who Reported They Had Not Had a Mammogram within the Preceding Two Years
    11.2
    Data Results 11.2     		How long has it been since you had your last mammogram?
    11.3
    Data Results 11.3     		Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
    11.4
    Data Results 11.4     		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?
    11.5
    Data Results 11.5     		How long has it been since your last breast exam?
    Crosstabulation Table:
    Percentage of Women Ages 40 Years and Older Who Reported They Had Not Had a Clinical Breast Breast Exam within the Preceding Two Years
    Percentage of Women Ages 50 Years and Older Who Reported They Had Not Had a Clinical Breast Breast Exam within the Preceding Two Years
    11.6
    Data Results 11.6     		Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
    11.7
    Data Results 11.7     		A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
    Crosstabulation Table:
    Percentage of Women Who Reported They Had Not Had a Pap Smear within the Preceding Two Years
    11.8
    Data Results 11.8     		How long has it been since you had your last Pap smear?
    11.9
    Data Results 11.9     		Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
    11.10
    Data Results 11.10     		Have you had a hysterectomy?
    11.11
    Data Results 11.11     		To your knowledge, are you now pregnant?
     
    CDC Core
    Section 12: HIV/AIDS
    12.1
    Data Results 12.1     		If you had a child in school, at what grade do you think he or she should begin receiving education in school about HIV infection and AIDS?
    12.2
    Data Results 12.2     		If you had a teenager who was sexually active, would you encourage him or her to use a condom?
    12.3
    Data Results 12.3     		What are your chances of getting infected with HIV, the virus that causes AIDS?
    Crosstabulation Tables:
    Percentage of Adults Ages 18 to 64 Years Who Reported that Their Risk of Contracting HIV was Medium or High
    12.4
    Data Results 12.4     		Have you donated blood since March 1985?
    12.5
    Data Results 12.5     		Have you donated blood in the past 12 months?
    12.6
    Data Results 12.6     		Except for tests you may have had as part of blood donations, have you ever been tested for HIV?
    12.7
    Data Results 12.7     		Not including your blood donations, have you been tested for HIV in the past 12 months?
    12.8
    Data Results 12.8     		What was the main reason you had your last test for HIV?
    12.9
    Data Results 12.9     		Where did you have your last test for HIV?
    12.10
    Data Results 12.10     		Did you receive the results of your last test?
    12.11
    Data Results 12.11     		Did you receive counseling or talk with a health care professional about the results of your test?
     
    Access to State-Added HIV Testing in Pregnancy Module
     
    CDC Optional
    Module 1: Diabetes
    1
    Data Results CO 1.1     		How old were you when you were told you have diabetes?
    2
    Data Results CO 1.2     		Are you now taking insulin?
    3
    Data Results CO 1.3     		Are you now taking diabetes pills?
    4
    Data Results CO 1.4     		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.
    5
    Data Results CO 1.5     		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.
    6
    Data Results CO 1.6     		Have you had any sores or irritations on your feet that took more than four weeks to heal?
    7
    Data Results CO 1.7     		About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
    8
    Data Results CO 1.8     		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"?
    9
    Data Results CO 1.9     		About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?
    10
    Data Results CO 1.10     		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.
    11
    Data Results CO 1.11     		Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
    12
    Data Results CO 1.12     		Have you ever taken a course or class in how to manage your diabetes yourself?
     
    State-Added
    Module 1: Diabetes
    1
    Data Results SA 1.1     		Is paying for your diabetes supplies a problem?
    2
    Data Results SA 1.2     		When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?
    3
    Data Results SA 1.3     		Who decides when you need your next diabetes check-up?
    4
    Data Results SA 1.4     		Were you hospitalized during the past two years?
    5
    Data Results SA 1.5     		What was the reason for your most recent hospitalization?
     
    State-Added
    Module 2: HIV Testing in Pregnancy
    1
    Data Results SA 2.1     		Have you been pregnant during the past two years?
    2
    Data Results SA 2.2     		Did your doctor offer you an HIV test during your last pregnancy?
     
    CDC Optional
    Module 10: Immunization
    1
    Data Results CO 10.1     		During the past 12 months, have you had a flu shot?
    Crosstabulation Tables:
     
     
    Percentage of Adults Ages 65 Years and Older Who Did Not Get Immunized Against Influenza During the Past 12 Months
    Percentage of Adults with Asthma Who Did Not Get Immunized Against Influenza During the Past 12 Months
    Percentage of Adults with Diabetes Who Did Not Get Immunized Against Influenza During the Past 12 Months
    2
    Data Results CO 10.2     		Have you ever had a pneumonia vaccination?
    Crosstabulation Tables:
     
     
    Percentage of Adults Ages 65 Years and Older Who Have Never Been Immunized Against Pneumococcal Disease
    Percentage of Adults with Asthma Who Have Never Been Immunized Against Pneumococcal Disease
    Percentage of Adults with Diabetes Who Have Never Been Immunized Against Pneumococcal Disease
     
    CDC Optional (M) & State-Added (D)
    Module 15: Quality of Life and Care-Giving
    1 (D1)
    Data Results SA 15.1     		How often do you get the social and emotional support you need?
    2 (D2)
    Data Results SA 15.2     		In general, how satisfied are you with your life?
    3 (D3)
    Data Results SA 15.3     		Are you limited in the kind or amount of work you can do because of any impairment or health problem?
    4 (D4)
    Data Results SA 15.4     		Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?
    5 (D5)



    Data Results:     		If you use special equipment or help from others to get around, what type do you use? [Choose up to 3 options.]
    6 (D6)
    Data Results SA 15.6     		Using special equipment or help, what is the farthest distance that you can go?
    7 (D7)
    Data Results SA 15.7     		What is the farthest distance you can walk by yourself, without any special equipment or help from others?
    8 (M1)
    Data Results CO 15.8     		Are you limited in any way in any activities because of any impairment or health problem?
    9 (M2)
    Data Results CO 15.9     		What is the MAJOR impairment or health problem that limits your activities?
    10 (M3)
    Data Results CO 15.10     		For HOW LONG have your activities been limited because of your major impairment or health problem?
    11 (M4)
    Data Results CO 15.11     		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?
    12 (M5)
    Data Results CO 15.12     		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?
    13 (M6)
    Data Results CO 15.13     		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?
    Crosstabulation Tables:
    Percentage of Adults who are Limited due to Pain
    14 (M7)
    Data Results CO 15.14     		During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?
    Crosstabulation Tables:
    Percentage of Adults with Depressive Symptoms
    15 (M8)
    Data Results CO 15.15     		During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?
    Crosstabulation Tables:
    Percentage of Adults Who Reported Feeling Worried, Tense, or Anxious on 14 or More Days in the Past 30 Days
    16 (M9)
    Data Results CO 15.16     		During the past 30 days, for about how many days have you felt that you did not get ENOUGH REST or SLEEP?
    Crosstabulation Tables:
    Percentage of Adults Who Reported They Did Not Get Enough Rest or Sleep on 14 or More Days in the Past 30 Days
    17 (M10)
    Data Results CO 15.17     		During the past 30 days, for about how many days have you felt VERY HEALTHY and FULL OF ENERGY?
    Crosstabulation Tables:
    Percentage of Adults Who Reported They Felt Very Healthy and Full of Energy on 16 or Fewer Days in the Past 30 Days
    18 (M11)
    Data Results CO 15.18     		Earlier you reported that due to your impairment you need some assistance from another person with your PERSONAL CARE needs. Who usually helps you with your personal care needs, such as eating, bathing, dressing, or getting around the house?
    19 (M12)
    Data Results CO 15.19     		Is the assistance you receive to meet your personal care needs:
    • Usually adequate
    • Sometimes adequate
    • Rarely adequate
    20 (M13)
    Data Results CO 15.20     		Earlier you reported that due to your impairment you need some assistance from another person with your ROUTINE needs. Who usually helps you with handling your routine needs, such as everyday household chores, shopping, or getting around for other purposes?
    21 (M14)
    Data Results CO 15.21     		Is the assistance you receive to meet your routine needs:
    • Usually adequate
    • Sometimes adequate
    • Rarely adequate
    22 (D8)
    Data Results SA 15.22     		Is there anyone [fill in (else) if "yes" to Q3, Q4, or Q8 or b-m to Q5] in your household who is LIMITED in any way in any activities because of any impairment or health problem?
    23a (D9) How old are these people? a. person 1
    23b (D9) How old are these people? b. person 2
    23c (D9) How old are these people? c. person 3
    23d (D9) How old are these people? d. person 4
    23e (D9) How old are these people? e. person 5
     
    CDC Optional
    Module 14: Arthritis
    1
    Data Results CO 14.1     		During the past 12 months, have you had pain, aching, stiffness or swelling in or around a joint?
    Crosstabulation Table:
    Percentage of Adults with Arthritis or Chronic Joint Symptoms
    2
    Data Results CO 14.2     		Were these symptoms present on most days for at least one month?
    3
    Data Results CO 14.3     		Are you now limited in any way in any activities because of joint symptoms?
    4
    Data Results CO 14.4     		Have you ever been told by a doctor that you have arthritis?
    5
    Data Results CO 14.5     		What type of arthritis did the doctor say you have?
    6
    Data Results CO 14.6     		Are you currently being treated by a doctor for arthritis?
     
    CDC Optional
    Module 5: Health Care Satisfaction
    1
    Data Results CO 5.1     		Do you have one person you think of as your personal doctor or health care provider?
    Crosstabulation Table:
    Percentage of Adults with No Personal Doctor or Health Care Provider
    2
    Data Results CO 5.2     		In the last 12 months, how many times did you go to an emergency room to get care for yourself?
    3
    Data Results CO 5.3     		In the last 12 months, [fill in "not counting times you went to an emergency room" if Q2=1-76], how many times did you go to a doctor’s office or clinic to get care for yourself?
    4
    Data Results CO 5.4     		In the last 12 months, how often did doctors or other health providers listen carefully to you?
    5
    Data Results CO 5.5     		In the last 12 months, how often did doctors or other health providers explain things in a way you could understand?
    6
    Data Results CO 5.6     		In the last 12 months, how often did doctors or other health providers show respect for what you had to say?
    7
    Data Results CO 5.7     		In the last 12 months, how often did doctors or other health providers spend enough time with you?
    8
    Data Results CO 5.8     		We want to know your rating of all your health care in the last 12 months from all doctors and other health providers. Use any number from 1 to 5 where 1 is the worst health care possible, and 5 the best health care possible. How would you rate all your health care?
     
    State-Added
    Module 3: Physician Characteristics
    1
    Data Results SA 3.1     		Are you able to see the same doctor every time or nearly every time you have a routine check-up or care for a medical condition?
    2
    Data Results SA 3.2     		Other than vitamins or antibiotics, do you take any medication that is prescribed by your doctor on a daily basis for control of a medical problem?
    3
    Data Results SA 3.3     		What is the medical specialty of your doctor?
    4
    Data Results SA 3.4     		What is the sex of your doctor?
    5
    Data Results SA 3.5     		About how old do you think your doctor is?
    6
    Data Results SA 3.6     		About how long has this doctor been caring for you?
    7
    Data Results SA 3.7     		During the past two years, was there a time that you thought you needed to see a specialist but were unable to get a referral?
    8
    Data Results SA 3.8     		Who decides when you need your next appointment?
    9
    Data Results SA 3.9     		How would you rate your doctor’s medical skill?
     
    State-Added
    Module 4: End-of-Life Issues
    1
    Data Results SA 4.1     		Have you prepared any legal documents such as a living will that would help your family make health care decisions for you if you were unable to make them for yourself?
    2
    Data Results SA 4.2     		During the past five years, were you involved in the care of a friend or a close family member who died of cancer?
    3
    Data Results SA 4.3     		On average, how much pain did this person have during the last three months they were alive?
    4
    Data Results SA 4.4     		Did this person’s health care provider prescribe any medications to help control pain?
    5a
    Data Results SA 4.5a     		Were there any prescribed pain medications that this person was supposed to use, but:
    a. did not get because of the cost?
    5b
    Data Results SA 4.5b     		Were there any prescribed pain medications that this person was supposed to use, but:
    b. used less often than prescribed in order to stretch them out because of the cost?
    5c
    Data Results SA 4.5c     		Were there any prescribed pain medications that this person was supposed to use, but:
    c. did not use as prescribed because of the side effects?
    5d
    Data Results SA 4.5d     		Were there any prescribed pain medications that this person was supposed to use, but:
    d. did not use as prescribed because they were afraid of getting addicted or hooked?
    6
    Data Results SA 4.6     		During the last three months this person was alive, what was the specialty of the physician providing most of the care for this person?
    7
    Data Results SA 4.7     		During the last three months this person was alive, did this person receive care through a hospice?
    8a
    Data Results SA 4.8a     		During the last three months this person was alive, did this person experience any of the following medical problems?
    a. confusion, delirium or other altered mental states
    8b
    Data Results SA 4.8b     		During the last three months this person was alive, did this person experience any of the following medical problems?
    b. bed sores
    8c
    Data Results SA 4.8c     		During the last three months this person was alive, did this person experience any of the following medical problems?
    c. loss of bowel control
    8d
    Data Results SA 4.8d     		During the last three months this person was alive, did this person experience any of the following medical problems?
    d. loss of kidney or bladder control
    8e
    Data Results SA 4.8e     		During the last three months this person was alive, did this person experience any of the following medical problems?
    e. severe fatigue
    8f
    Data Results SA 4.8f     		During the last three months this person was alive, did this person experience any of the following medical problems?
    f. mouth sores
    8g
    Data Results SA 4.8g
    		During the last three months this person was alive, did this person experience any of the following medical problems?
    g. depression that was treated with medicine
    8h
    Data Results SA 4.8h     		During the last three months this person was alive, did this person experience any of the following medical problems?
    h. open wounds other than bed or mouth sores
    9
    Data Results SA 4.9     		Where did the patient live for most of the time during the last three months of life?
    10
    Data Results SA 4.10     		How would you rate the medical care this person received to ease their suffering?
    11
    Data Results SA 4.11     		Where did this person die?
    12
    Data Results SA 4.12     		About how many years ago did this person die?
    13
    Data Results SA 4.13     		Did the person receive any psychological or spiritual counseling to help them cope with dying?
     
    State-Added
    Module 5: Health of Children (short version)
    1
    Data Results SA 5.1     		What is the age of the youngest child under age 18 in your household?
    2
    Data Results SA 5.2     		Would you say that in general the youngest child’s health is:
    • Excellent
    • Very Good
    • Good
    • Fair
    • Poor
    3
    Data Results SA 5.3     		Is the youngest child limited in any way in any activities because of any impairment or health problem?
     
    State-Added
    Module 6: Tobacco Cessation
    1a
    Data Results SA 6.1a     		Have you ever used any of the following methods even for one day to help you quit smoking:
    a. Nicotine gum
    1b
    Data Results SA 6.1b     		Have you ever used any of the following methods even for one day to help you quit smoking:
    b. Nicotine patch
    1c
    Data Results SA 6.1c     		Have you ever used any of the following methods even for one day to help you quit smoking:
    c. Nicotine nasal spray
    1d
    Data Results SA 6.1d     		Have you ever used any of the following methods even for one day to help you quit smoking:
    d. Nicotine inhaler
    1e
    Data Results SA 6.1e     		Have you ever used any of the following methods even for one day to help you quit smoking:
    e. Zyban, also called burproprion or wellbutrin - a pill
    1f
    Data Results SA 6.1f     		Have you ever used any of the following methods even for one day to help you quit smoking:
    f. A quit smoking class or group
    1g
    Data Results SA 6.1g     		Have you ever used any of the following methods even for one day to help you quit smoking:
    g. 'Cold turkey' or quitting on your own
    2
    Data Results SA 6.2     		Are you seriously considering quitting cigarettes in the next 6 months?
    3
    Data Results SA 6.3     		Are you planning to quit in the next 30 days?
     
    State-Added
    Module 7: Preventive Counseling Services
    1
    Data Results SA 7.1     		Has a doctor or other health professional ever talked with you about getting a mammogram?
    2
    Data Results SA 7.2     		Has a doctor or other health professional ever talked with you about your diet or eating habits?
    3
    Data Results SA 7.3     		Has a doctor or other health professional ever talked with you about physical activity or exercise?
    4
    Data Results SA 7.4     		(Has a doctor or other health professional ever talked with you) about injury prevention, such as safety belt use, helmet use, or smoke detectors?
    5
    Data Results SA 7.5     		(Has a doctor or other health professional ever talked with you) about drug abuse?
    6
    Data Results SA 7.6     		(Has a doctor or other health professional ever talked with you) about alcohol use?
    7
    Data Results SA 7.7     		(Has a doctor or other health professional) ever advised you to quit smoking?
    8
    Data Results SA 7.8     		(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?