About how much do you weigh without shoes?

About how tall are you without shoes?

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

Are you Hispanic or Latino?

Are you of Spanish or Hispanic origin?

Are you:

• Married
• Divorced
• Widowed
• Separated
• Never been married
• A member of an unmarried couple

Do you have more than one telephone number in your household?

Do you have more than one telephone number in your household? Do not include cell phones or numbers that are only used by a computer or fax machine.

During the past 12 months, has your household been without telephone service for 1 week or more? Do not include interruptions of phone service due to weather or natural disasters.

During the past 12 months, has your household been without telephone service for 1 week or more? Do not include when services is interrupted by weather or natural disasters.

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?

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? Active duty does not inlcude training for the Reserves or National Guard, but does inlcude activation, for example, for the Persian Gulf War.

How many adult members of your household currently use a cell phone for any purpose?

How many children less than 18 years of age live in your household ?

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

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

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

How many of these are residential numbers?

How many of these phone numbers are residential numbers?

How many residential telephone numbers do you have?

How much did you weigh a year ago?

How much would you like to weigh?

In the last 12 months have you received some or all of your health care from VA facilities?

Indicate sex of respondent. Ask Only if Necessary

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
• 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

To your knowledge, are you now pregnant?

Was the change between your current weight and your weight a year ago intentional?

What county do you live in?

What is the highest grade or year of school you completed?

What is your age?

What is your race?

What is your ZIP Code where you live?

Which of the following best describes your current military status?

Which of the following categories best describes your annual household income from all sources?

Which of the following best describes your service in the United States Military?

Which one of these groups would you say best represents your race?

Which one or more of the following would you say is your race?

Are you a parent or a guardian of this child?

How are you related to the child?

How are you related to the [randomly selected child]?

How is the youngest child in your household related to you?

How many children less than 18 years of age live in your household?

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

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

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

How many of the children in your household are aged 7 to 17?

Is the child Hispanic or Latino?

Is the [randomly selected child] child Hispanic or Latino?

Is the child a boy or a girl?

Previously, you indicated there were [number of children from core] children under age 18 in your household. What is the age of the [randomly selected child - oldest, second oldest, etc.] child?

What is the age of the oldest child in your household under the age of 15?

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

What is the age of the oldest child in your household under the age of 18?

What is the age of the youngest child in your household?

What is the age of the youngest child under age 18 in your household?

What is the birth month and year of the “Xth” child?

What is the gender of this child?

Which one or more of the following would you say is the race of the child?
[Check all that apply]

Which one of these groups would you say best represents the race of the [randomly selected child]?

Would you say you are the parent or guardian who spends the most time caring for the [age] year old child?

Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are put on by a dentist or dental hygienist. They are different from fillings, caps, crowns, and fluoride treatments. Has the [randomly selected child] ever had dental sealants placed on [her/his] teeth?

Dental sealants are special plastic coatings that are painted on the tops of the back teeth to prevent tooth decay. They are put on by a dentist or dental hygienist. They are different from fillings, caps, crowns, and fluoride treatments. How many of the children aged 7 to 17 living in your household, ever had dental sealants placed on their teeth?

How many of the children in your household are aged 7 to 17?

During the past month, have you often been bothered by feeling down, depressed, or hopeless?

During the past month, have you often been bothered by little interest or pleasure in doing things?

Has a doctor or nurse ever told you that you had depression?

Have you ever had any other alternative / complementary treatments for depression? Alternative / complementary treatments are, for example, massage, acupuncture, or touch therapy.

Have you ever had counseling therapy for depression?

Have you ever taken a prescription medication for depression?

Have you ever taken any over the counter medications for depression? Over the counter medications are, for example, St. John’s Wort, ginseng, or any herbal medication.

To your knowledge, how helpful is physical activity, such as swimming, jogging, brisk walking, or biking, in improving mood and relieving depression?

About how long has it been since you were diagnosed with depression?

During the past 12 months, have you had a period of two weeks or longer when you felt sad, discouraged or uninterested?

Did you receive any treatment for your sadness, discouragement or lack of interest at any time in the past 12 months by a medical doctor or other health professionals? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)

During the past 12 months, did you get a precscription medicine for your sadness, discouragement or lack of interest?

During the past 12 months, did you receive counseling or therapy from a medical doctor or other health professional for your sadness, discouragement or lack of interest? (By health professional we mean psychologists, counseolors, spiritual advisors, herbalists, acupuncturists, and other healing professionals.)

What was the main reason you did not receive treatment that you needed for your sadness, discouragement or lack of interest in the past 12 months?

During the past 12 months, how many different times have you stayed overnight or longer in a hospital to receive treatment for your sadness, discouragement or lack of interest?

A test for "A one C" measures the average level of blood sugar over the past three months. About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for "A one C"?

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 last year has a doctor, nurse, or other health professional checked you for hemoglobin "A one C"?

About how many times in the last year has a health professional checked your feet for any sores or irritations?

About how many times in the last year have you seen a doctor, nurse, or other health professional for your diabetes?

About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

About how many times in the past 12 months has a health professional checked your feet for any sores or irritations?

About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?

About how often do you check your blood for glucose or sugar? Include times when checked by a family member or friend, but do not include times when checked by a health professional.

About how often do you check your feet for any sores or irritations? Include times when checked by a family member or friend, but do not include times when checked by a health professional.

Are you now taking diabetes pills?

Are you now taking insulin?

Currently, about how often do you use insulin?

Do you take insulin injections, diabetes pills, or both?

Earlier you said that you check your blood for sugar or glucose. Please tell me waht steps you take when you find that your blood sugar or glucose is elevated. Include times when you are helped by family members or friends to take those steps. [Mark all that apply]

• Exercise
• Take or adjust my does of insulin
• Go to the nearest emergency room
• Call my doctor
• Nothing
• Other (specify:_____)

Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?

Have you ever been told by a doctor that you have diabetes?

Have you ever heard of glycosylated hemoglobin (gli-KOS-ilated he-mo-glo-bin) or hemoglobin "A one C"?

Have you ever taken a course or class in how to manage your diabetes yourself?

Have you had a baby weighing more then 9 pounds at birth?

Have you had any sores or irritations on your feet that took more than four weeks to heal?

Have you talked to a dietician (diet specialist), or nutritionist about your diabetes during the past 5 years?

How much of the time does your vision limit you in reading print in a newspaper, magazine, recipe, menu, or numbers on the telephone?

How much of the time does your vision limit you in recognizing people or objects across the street?

How much of the time does your vision limit you in watching television?

How often are you told to remove your socks and shoes before you see the doctor or other health professional for your diabetes? Would you say always, nearly always, sometimes, or seldom?

How often do you have trouble telling the difference between a one dollar bill and a five dollar bill?

How often does your doctor ask to see a record of what your blood sugars are at home?

How old were you when you were told you had diabetes?

How old were you when you were told you have diabetes?

In general, how would you rate your vision when wearing glasses or contacts if needed?

Is paying for your diabetes supplies a problem?

Knowing that you have diabetes, please tell me what steps you take to avoid having an elevated blood sugar. [Mark all that apply}

• Control carbohydrate intake/awareness of carbohydrate intake
• Count carbohydrates
• Exercise
• Test blood sugar or glucose
• Adjust medication
• Nothing
• Other (specify:_____)

Please answer yes or no to the following questions. Has your diabetes caused you any of the following health problems?
a. Permanent loss of vision
b. Loss of kidney function
c. Skin sores or ulcers
d. Amputation
e. Heart disease
f. Numbness, tingling, or pain in feet or legs
g. Lose protein in urine

Were you hospitalized during the past two years?

What was the reason for your most recent hospitalization?

When you go to the doctor for your diabetes, how often does your doctor tell you when to return for your next diabetes check up?

When you go to your doctor or other health professional for your diabetes, are you usually told to remove your socks and shoes before you see the doctor or other health professional?

When you go to your doctor for your diabetes, are you usually told to remove your socks and shoes before you see the doctor?

When you last visited your doctor for your diabetes did he or she examine your feet?

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.

When you go to the doctor or other health professional for your diabetes, how often does your doctor or other health professional tell you when to return for your next diabetes check-up?

Which of the following family members, if any, have been told by a doctor that they have diabetes? Include only blood relatives. Do not include adoptive or those related only by marriage.

While stopped in a vehicle at a traffic light, how often do you have trouble reading the license plate on the care in front of you?

Who decides when you need your next diabetes check-up?

Have you had a test for high blood sugar or diabetes within the past three years?

Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?

Which of the following family members, if any, have been told by a doctor that they have diabetes? Include only blood relatives. Do not include adoptive or those related only by marriage.

Have you had a baby weighing more then 9 pounds at birth?

How often do you eat hot dogs or lunch meats such as ham or other cold cuts?

How often do you eat bacon or sausage?

How often do you eat pork other than ham, bacon, or sausage?

How often do you eat hamburgers, cheeseburgers, or meat loaf?

How often do you eat beef other than hamburgers, cheeseburgers, or meat loaf?

How often do you eat fried chicken?

How often do you eat french fries or fried potatoes?

How often do you eat cheese or cheese spreads, not including cottage cheese?

How often do you eat doughnuts, cookies, cake, pastry, or pies?

How often do you usually eat snacks, such as chips or popcorn?

How often do you usually add butter or margarine to bread, rolls, or vegetables?

How many eggs do you usually eat?

How many glasses (8 oz.) of whole milk do you usually drink? Remember to include drinks made with whole milk or milk on cereal. Do not include low-fat milk, such as skim milk or 2% milk.

Are you limited in any way in any activities because of any impairment or health problem? (Asked of all respondents.)

Are you limited in any way in any activities because of physical, mental, or emotional problems? (Asked of all respondents.)

Are you limited in the kind or amount of housework you can do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Are you limited in the kind or amount of work you can do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Are you limited in the kind or amount of work you can do because of any impairment or health problem?
(Asked of all respondents.)

Are you limited in the kind or amount of work you could do because of any impairment or health problem?
(Asked of respondents who where between the ages of 18 - 64.)

Are you restricted in any way to services you need such as doctor, counseling, case management, or financial?

Because of an impairment or health problem do you have problems with any of the following:

....thinking, remembering or controlling emotions?

[Because of an impairment or health problem do you have problems]:

....seeing, hearing or communicating?

[Because of an impairment or health problem do you have problems]:

....heart, blood pressure or breathing?

[Because of an impairment or health problem do you have problems]:


....digestive system?

[Because of an impairment or health problem do you have problems]:

....nerves, muscles or joints?

[Because of an impairment or health problem do you have problems]:


....other bodily functions which are affected?

Because of any impairment or health problem, do you have any trouble learning, remembering, or concentrating?

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?
(Asked of respondents who where 65 and older.)

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?
(Asked of all respondents.)

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?
(Asked of respondents who where 65 and older.)

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?
(Asked of all respondents.)

Do you now consider yourself to be a person with a disability?

Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?

Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? Include occasional use or use in certain circumstances.

Do you still experience problems as a result of a head injury?

Does any impairment or health problem keep you from working at a job or business?
(Asked of respondents who where between the ages of 18 - 64.)

Does any impairment or health problem NOW keep you from doing any housework at all?
(Asked of respondents who where between the ages of 18 - 64.)

Does any impairment or health problem NOW keep you from working at a job or business?
(Asked of respondents who where between the ages of 18 - 64.)

Does your impairment or health problem affect your ability with any of the following

....go to school or work?

[Does your impairment or health problem affect your ability to]:

....perform personal care activities including bathing, dressing, grooming, using the toilet or getting in and out of bed?

[Does your impairment or health problem affect your ability to]:

....perform household activities including paying bills, shopping, cooking, or cleaning the house?

[Does your impairment or health problem affect your ability to]:

....participate in physical activity?

[Does your impairment or health problem affect your ability to]:

....move around including walking, using stairs, lifting or carrying objects?

During the past 12 months, have you fallen?
(Asked of respondents who where 65 and older.)

During the past 12 months, have you had to see a doctor or nurse because you were injured when you fell?
(Asked of respondents who where 65 and older.)

During the past 30 days, for about how many days did PAIN make it hard for you to do your usual activities, such as self-care, work, or recreation?

During the past 30 days, for about how many days have you felt SAD, BLUE, or DEPRESSED?

During the past 30 days, for about how many days have you felt that you did not get ENOUGH REST or SLEEP?

During the past 30 days, for about how many days have you felt VERY HEALTHY and FULL OF ENERGY?

During the past 30 days, for about how many days have you felt WORRIED, TENSE, or ANXIOUS?

During the past 5 years, have you been admitted to a hospital?
(Asked of respondents who where 65 and older.)

During the past 5 years, were you ever admitted to a nursing home?
(Asked of respondents who where 65 and older.)

During the past week, have you needed to change your clothes or bed sheets because you lost control of your bladder?
(Asked of respondents who where 65 and older.)

During the past week, have you needed to change your clothes or bed sheets because you lost control of your bowels?
(Asked of respondents who where 65 and older.)

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?

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?

For HOW LONG have your activities been limited because of your major impairment or health problem?

Has a doctor or other health professional given you information about community or self-help resources that can help you manage your condition?

Have you ever had a head injury which caused you to lose consciousness or completely black out?

Have you ever sustained a spinal cord injury?

How often do you get the social and emotional support you need?

How old are these people?

If you use special equipment or help from others to get around, what type do you use?

In general, how satisfied are you with your life?

Including yourself, how many people in your household have received medical care or are limited in any way in any activities as a result of an injury to their head or brain?

Is the assistance you receive to meet your personal care needs:  Usually adequate, Sometimes adequate, Rarely adequate

Is the assistance you receive to meet your routine needs: Usually adequate, Sometimes adequate, Rarely adequate

Is there anyone [insert "else" if respondent already indicated that they have a limitation] in your household who is LIMITED in any way in any activities because of any impairment or health problem?

Is this impairment or health problem the result of a work-related illness or injury?

Is this restriction due to any of the following?

….lack of transportation?

[Is this restriction due to]:

….cost of services?

[Is this restriction due to]:

….physical access to buildings, offices or tools needed?

[Is this restriction due to]:

….restriction by another person such as a personal attendant or family member?

[Is this restriction due to]:

….lack of communication aids such as interpreters or alternate formats?

Is your ability to move around due to any of the following:… paralysis?

Note: If asked "Paralysis is defined as loss of function or feeling that affects the ability to move your arms or legs but does not include amputation or missing limbs"

[Is your ability to move around due to]:
… amputation or missing limb?

[Is your ability to move around due to]:
…a chronic disease such as diabetes or arthritis?

[Is your ability to move around due to]:
…something else?

Using special equipment or help, what is the farthest distance that you can go?

What is the farthest distance you can walk by yourself, without any special equipment or help from others?

What is the MAJOR impairment or health problem that limits your activities?

What were you doing MOST of the past 12 months?
(Asked of respondents who where between the ages of 18 - 64.)

These next questions are about experiences you may have in your day-to-day life. How often do any of the following things happen to you? Would you say this happens: almost every day, at least once a week, a few times a month, a few times a year, less than once a year or never.

You are treated with less respect than other people are.

People act as if they think you are not smart.

People act as if they’re better than you are.

You are called names or insulted.

What do you think is the main reason for the negative experiences you have just told me about?

• Age
• Gender
• Race / Ethnicity
• Religion
• Weight
• Sexual Orientation
• Education or income level
• Physical disability status
• Some other aspect of physical appearance
• No particular reason / Reasons vary too much to say
• Other (specify: _______ )

Have you completed a Durable Power of Attorney for Health Care Decisions? This is a legal document that allows you to name someone to make health care decisions for you if you should ever become unable to speak for yourself?

[Interviewer note: If asked “This is different from a Living Will”]

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

During the past 30 days, how many times have you driven when you've had perhaps too much to drink?

During the past month, how many times have you ridden with a driver who has had perhaps too much to drink?