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.)