|
|
|
Start of C. Health
|
| |
C001
Self-report of health
NEXT I HAVE SOME QUESTIONS ABOUT YOUR HEALTH. WOULD YOU SAY YOUR HEALTH IS VERY GOOD, GOOD, FAIR, POOR OR VERY POOR?
1) Very good 2) Good 3) Fair 4) Poor 5) Very poor
|
| |
C002
Doctor diagnosed disability
HAVE YOU EVER RECEIVED DISABILITY DIAGNOSIS FROM A DOCTOR?
1) yes 5) no
|
| |
If Doctor diagnosed disability = 1 »
|
|
| |
|
| |
C003
Disability
WHAT WAS THE IMPAIRMENT OR HEALTH PROBLEM? PLEASE LIST ALL THAT APPLY.
1) Physically handicapped
2) Brain damage
3) Vision problem
4) Hearing problem
5) Speech impediment
6) Kidney trouble
7) Heart problem
8) Psychiatric problems
9) Autism
10) Refuse to answer
11) Don't know
|
| |
|
C004
Limit work due to health problem
DOES THIS IMPAIRMENT OR HEALTH PROBLEM LIMIT THE KIND OR AMOUNT OF PAID WORK YOU CAN DO?
1) Yes, very much so 2) Yes, some degree 3) No, not much 4) No, not at all
|
| |
C005
Diagnosis high blood pressure
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE HIGH BLOOD PRESSURE OR HYPERTENSION?
1) yes 5) no
|
| |
If Diagnosis high blood pressure = 1 »
|
|
| |
|
| |
C006
Year/month high blood pressure first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR HYPERTENSION FIRST DIAGNOSED? ____________________
190000..200612
|
| |
|
| |
C007
Medication and treatment for high blood pressure
IN ORDER TO LOWER YOUR BLOOD PRESSURE, ARE YOU CURRENTLY TAKING ANY MEDICATION OR OTHER TREATMENTS?
1) yes 5) no
|
| |
|
| |
C008
Limit daily activities due to high blood pressure
DOES THE HIGH BLOOD PRESSURE OR HYPERTENSION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
C009
Diagnosis diabetes
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE DIABETES OR HIGH BLOOD SUGAR?
1) yes 5) no 99) Don't know
|
| |
If Diagnosis diabetes = 1 »
|
|
| |
|
| |
C010
Year/month diabetes first diagnosed
IN WHAT YEAR AND MONTH WAS THAT FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
| |
C011
Medication and treatment for diabetes
ARE YOU NOW USING MEDICATION THAT YOU SWALLOW OR USING INSULIN INJECTIONS TO TREAT OR CONTROL YOUR DIABETES?
1) yes 5) no
|
| |
|
| |
C012
Limit daily activities due to diabetes
DOES YOUR DIABETES LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
C013
Diagnosis cancer or malignant tumor
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE CANCER OR A MALIGNANT TUMOR, EXCLUDING MINOR SKIN CANCERS?
1) yes 5) no
|
| |
If Diagnosis cancer or malignant tumor = 1 »
|
|
| |
|
| |
C014
Year/month cancer or malignant tumor first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR CANCER OR A MALIGNANT TUMOR, EXCLUDING MINOR SKIN CANCERS, FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
| |
C015
Which organ or part has cancer
IN WHICH ORGAN OR PART OF YOUR BODY DO YOU HAVE CANCER?
1) Liver 2) Stomach 3) Lung 4) Colon 5) Thyroid 6) Breast 7) Cervix 8) Ovary 9) Other
|
| |
|
| |
If Which organ or part has cancer = 9 »
|
|
| |
|
|
| |
|
C016
Other (specify)
PLEASE SPECIFY OTHER'. _______________________
STRING
|
| |
|
|
| |
C017
Medicine or treatment for cancer (symptoms mitigation)
ARE YOU NOW TAKING ANY MEDICATION TO ALLEVIATE SYMPTOMS (PAIN, NAUSEA, RASH, ETC.) OR RECEIVING TREATMENT SUCH AS CHEMOTHERAPY?
1) yes 5) no
|
| |
|
| |
C018
Limit daily activities due to cancer
DOES YOUR CANCER LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
| |
C019
Diagnosis chronic lung disease
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE CHRONIC LUNG DISEASE SUCH AS CHRONIC BRONCHITIS OR EMPHYSEMA?
1) yes 5) no
|
| |
|
| |
If Diagnosis chronic lung disease = 1 »
|
|
| |
|
|
| |
|
C020
Year/month chronic lung disease first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR CHRONIC LUNG DISEASE FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
|
| |
|
C021
Medicine and treatment for chronic lung disease (pulmonary complaints)
ARE YOU NOW TAKING MEDICATION OR OTHER TREATMENT FOR YOUR LUNG CONDITION?
1) yes 5) no
|
| |
|
|
| |
|
C022
Limit daily activities due to lung disease
DOES YOUR LUNG CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C023
Diagnosis liver disease (fatty liver exception)
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE LIVER DISEASE? (ALL TYPES OF LIVER DISEASE EXCEPT FATTY LIVER)
1) yes 5) no 99) Don't know
|
| |
|
| |
C024
Year/month liver disease first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR LIVER DISEASE FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
| |
C025
Medicine and treatment for liver disease
ARE YOU NOW TAKING MEDICATION OR OTHER TREATMENT FOR YOUR LIVER DISEASE?
1) yes 5) no
|
| |
|
| |
C026
Limit daily activities due to liver disease
DOES YOUR LIVER CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
| |
C027
Diagnosis heart problems (heart attack, coronary heart disease, angina, congestive heart failure)
HAS A DOCTOR EVER TOLD YOU THAT YOU HAD A HEART ATTACK, CORONARY HEART DISEASE, ANGINA, CONGESTIVE HEART FAILURE, OR OTHER HEART PROBLEMS?
1) yes 5) no
|
| |
|
| |
If Diagnosis heart problems (heart attack, coronary heart disease, angina, congestive heart failure) = 1 »
|
|
| |
|
|
| |
|
C028
Year/month heart problems first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR HEART PROBLEM FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
|
| |
|
C029
Medicine and treatment for heart problems
ARE YOU NOW TAKING OR CARRYING MEDICATION OR RECEIVING TREATMENT FOR YOUR HEART PROBLEM?
1) yes 5) no
|
| |
|
|
| |
|
C030
Limit daily activities due to heart problems
DOES YOUR HEART CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C031
Diagnosis stroke
IF R CURRENTLY DRINKS, GO TO
1) yes 3) (vol) Possible stroke or transient ischemic attack (TIA) 5) No
|
| |
|
| |
If Diagnosis stroke != 5 »
|
|
| |
|
|
| |
|
C032
Year/month stroke first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR STROKE FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
|
| |
|
C033
Medicine and treatment for stroke
ARE YOU NOW TAKING ANY MEDICATIONS BECAUSE OF YOUR STROKE OR ITS COMPLICATIONS?
1) yes 5) no
|
| |
|
|
| |
|
C034
Limit daily activities due to stroke
DOES YOUR CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C035
Diagnosis emotional, nervous, or psychiatric problems
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE ANY EMOTIONAL, NERVOUS, OR PSYCHIATRIC PROBLEMS?
1) yes 5) no
|
| |
|
| |
If Diagnosis emotional, nervous, or psychiatric problems = 1 »
|
|
| |
|
|
| |
|
C036
Year/month emotional, nervous, or psychiatric problems first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR EMOTIONAL, NERVOUS, OR PSYCHIATRIC PROBLEMS FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
|
| |
|
C037
Medicine and treatment for emotional, nervous, or psychiatric problems
DO YOU NOW TAKE TRANQUILIZERS, ANTIDEPRESSANTS, SEDATIVES OR SLEEPING PILLS OR GET PSYCHIATRIC OR PSYCHOLOGICAL TREATMENT FOR YOUR PROBLEMS?
1) yes 5) no
|
| |
|
|
| |
|
C038
Limit daily activities due to emotional, nervous, or psychiatric problems
DOES YOUR CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C039
Diagnosis arthritis or rheumatism
HAS A DOCTOR EVER TOLD YOU THAT YOU HAVE ARTHRITIS OR RHEUMATISM?
1) yes 5) no 99) Don't know
|
| |
|
| |
If Diagnosis arthritis or rheumatism = 1 »
|
|
| |
|
|
| |
|
C040
Year/month arthritis or rheumatism first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR ARTHRITIS OR RHEUMATISM FIRST DIAGNOSED? ___________
190000..200612
|
| |
|
|
| |
|
C041
Medicine and treatment for arthritis or rheumatism
ARE YOU CURRENTLY TAKING ANY MEDICATION OR OTHER TREATMENTS FOR YOUR ARTHRITIS OR RHEUMATISM?
1) yes 5) no
|
| |
|
|
| |
|
C042
Limit daily activities due to arthritis or rheumatism
DOES YOUR ARTHRITIS LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C043
Ever medical treatment due to traffic accident
HAVE YOU EVER BEEN IN A TRAFFIC ACCIDENT AND RECEIVED MEDICAL TREATMENT?
1) yes 5) no 99) Don't know
|
| |
|
| |
If Ever medical treatment due to traffic accident = 1 »
|
|
| |
|
|
| |
|
C044
Year/month recent injury caused by traffic accident
IN WHAT YEAR AND MONTH, WERE YOU INJURED BY A TRAFFIC ACCIDENT? IF YOU HAVE BEEN IN MORE THAN TWO ACCIDENTS, PLEASE TELL ME ABOUT THE MOST RECENT ONE. ____________
190000..200612
|
| |
|
|
| |
|
C045
Limt daily activities due to traffic accident injury
DOES YOUR INJURY CAUSED BY THE TRAFFIC ACCIDENT LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C046
Fallen in past two years
HAVE YOU FALLEN DOWN IN THE LAST TWO YEARS?
1) yes 5) no
|
| |
|
| |
C047
Number times fallen
HOW MANY TIMES DID YOU FALL IN THE LAST TWO YEARS? __________TIMES
1..100
|
| |
|
| |
C048
Serious injury due to fall
IN YOUR MOST RECENT FALL, DID YOU INJURE YOURSELF SERIOUSLY ENOUGH TO NEED MEDICAL TREATMENT?
1) yes 5) no
|
| |
|
| |
C049
Broken hip due to fall
HAVE YOU EVER FRACTURED YOUR HIP?
1) yes 5) no
|
| |
|
| |
C050
Limit daily activities due to injury fallen
DOES YOUR INJURY OR FRACTURE DUE TO THE FALL LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
| |
C051
Worry about falling
DO YOU WORRY ABOUT FALLING DOWN?
1) Not at all 3) A little bit 5) A lot
|
| |
|
| |
C052
Refrain activities due to fear of falling
ARE THERE ANY ACTIVITIES THAT YOU REFRAIN FROM DUE TO THE FEAR OF FALLING DOWN?
1) yes 5) no
|
| |
|
| |
|
|
| |
|
|
| |
|
C053
Diagnosis prostate illness (prostate hyperplasia)
HAVE YOU EVER BEEN DIAGNOSED WITH A PROSTATE ILLNESS SUCH AS PROSTATE HYPERPLASIA?
1) yes 5) no 99) Don't know
|
| |
|
|
| |
|
C054
Year/month prostate illness first diagnosed
IN WHAT YEAR AND MONTH WAS YOUR PROSTATE ILLNESS FIRST DIAGNOSED? _____________
190000..200612
|
| |
|
|
| |
|
C055
Medicine and treatment for prostate illness
ARE YOU NOW TAKING MEDIATION OR OTHER TREATMENT FOR YOUR PROSTATE ILLNESS?
1) yes 5) no
|
| |
|
|
| |
|
C056
Limit daily activities due to prostate illness
DOES YOUR PROSTATE CONDITION LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C057
Leak urine in LCY
THIS MIGHT NOT BE EASY TO TALK ABOUT, BUT DURING THE LAST 12 MONTHS, HAVE YOU LOST ANY AMOUNT OF URINE BEYOND YOUR CONTROL?
1) yes 5) no 99) Don't know
|
| |
|
|
| |
|
If Leak urine in LCY = 1 »
|
|
| |
|
|
|
| |
|
|
C058
Number days lost urine in last month
ON ABOUT HOW MANY DAYS IN THE LAST MONTH HAVE YOU LOST ANY URINE? _________ DAYS IF R DOESN'T KNOW OR REFUSES TO ANSWER TO C058, GO TO
0..31
|
| |
|
|
|
| |
|
|
If Number days lost urine in last month = 99 or Number days lost urine in last month = 98 »
|
|
| |
|
|
|
|
| |
|
|
|
C059
More than 5 days in last month
WAS THAT MORE THAN 5 DAYS?
1) yes 5) no 99) Don't know
|
| |
|
|
|
|
| |
|
|
|
If More than 5 days in last month = 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C060
More than 15 days in last month
WAS THAT MORE THAN 15 DAYS?
1) yes 5) no
|
| |
|
|
|
|
|
| |
|
|
C061
Use absorbent products for leaking urine
HAVE YOU EVER USED ANY ABSORBENT PRODUCTS SUCH AS PADS, SPECIAL GARMENTS, SANITARY NAPKINS, OR TOILET PAPER?
1) yes 5) no
|
| |
|
|
|
| |
C062
Wear glasses or contact lenses
NOW I HAVE SOME QUESTIONS ABOUT YOUR EYESIGHT. DO YOU USUALLY WEAR GLASSES OR CORRECTIVE LENS?
1) yes 3) Legally blind 5) no
|
| |
|
| |
If Wear glasses or contact lenses != 3 »
|
|
| |
|
|
| |
|
C063
Rate eyesight
IS YOUR EYESIGHT VERY GOOD, GOOD, FAIR, POOR, OR VERY POOR (USING/NOT USING GLASSES OR CORRECTIVE LENS AS USUAL)?
1) Very good 2) Good 3) Fair 4) Poor 5) Very poor
|
| |
|
|
| |
|
C064
Rate distal vision
HOW GOOD IS YOUR EYESIGHT FOR SEEING THINGS AT A DISTANCE, LIKE RECOGNIZING A FRIEND ACROSS THE STREET?
1) Very good 2) Good 3) Fair 4) Poor 5) Very poor
|
| |
|
|
| |
|
C065
Rate near vision
HOW GOOD IS YOUR EYESIGHT FOR SEEING THINGS UP CLOSE, LIKE READING ORDINARY NEWSPAPER PRINT?
1) Very good 2) Good 3) Fair 4) Poor 5) Very poor
|
| |
|
|
| |
|
C066
Cataract surgery
HAVE YOU EVER HAD CATARACT SURGERY?
1) yes 5) no
|
| |
|
|
| |
|
If Cataract surgery = 1 »
|
|
| |
|
|
|
| |
|
|
C067
Cataract surgery on one or both eyes
HAVE YOU HAD CATARACT SURGERY ON BOTH EYES OR JUST ONE?
1) One eye only 5) Both eyes
|
| |
|
|
|
| |
|
C068
Glaucoma treatment
HAS A DOCTOR EVER TREATED YOU FOR GLAUCOMA?
1) yes 5) no
|
| |
|
|
| |
|
C069
Limit daily activities due to vision
DOES YOUR EYESIGHT LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
C070
Wear hearing aid
NOW I HAVE SOME QUESTIONS ABOUT YOUR HEARING. DO YOU EVER WEAR A HEARING AID?
1) yes 5) no
|
| |
|
| |
C071
Rate hearing
IS YOUR HEARING VERY GOOD, GOOD, FAIR, POOR, OR VERY POOR USING A HEARING AID AS USUAL?
1) Very good 2) Good 3) Fair 4) Poor 5) Very poor
|
| |
|
| |
C072
Limit daily activities due to hearing
DOES YOUR HEARING LIMIT YOUR DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
| |
C073
Wear dentures
NOW I HAVE SOME QUESTIONS ABOUT YOUR DENTAL HEALTH. DO YOU WEAR DENTURES?
1) yes 5) no
|
| |
|
| |
C074
Rate chew for solid foods (without dentures)
HOW WELL CAN YOU CHEW SOLID FOODS SUCH AS MEAT OR APPLES WITHOUT THE HELP OF DENTURES?
1) Very well 2) Pretty well 3) Fair 4) Not well 5) Not at all
|
| |
|
| |
C075
Rate chew for solid foods (with dentures)
HOW EASILY CAN YOU CHEW SOLID FOODS SUCH AS MEAT OR APPLES WEARING DENTURES?
1) Very well 2) Pretty well 3) Fair 4) Not well 5) Not at all
|
| |
|
| |
C076
Types of pain
NOW I HAVE SOME QUESTIONS ABOUT BODY PAIN. ON WHAT PART OF YOUR BODY DO YOU FEEL PAIN? PLEASE LIST ALL PARTS OF BODY YOU ARE CURRENTLY FEELING PAIN.
1) Head/headache 2) Shoulder pain 3) Arm pain 4) Wrist pain 5) Fingers pain 6) Chest pain 7) Stomach (Stomachache) 8) Back pain 9) Buttocks pain 10) Leg pain 11) Knee pain 12) Ankle pain 13) Toes pain 14) No pain 15) Refuse to answer 16) Don't know
|
| |
|
| |
|
|
| |
|
|
| |
|
C077
Degree pain most of time-headache
HOW BAD IS THE HEADACHE?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C078
Degree pain most of time-shoulder
HOW BAD IS THE SHOULDER PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C079
Degree pain most of time-arm
HOW BAD IS THE ARM PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C080
Degree pain most of time-wrist
HOW BAD IS THE WRIST PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C081
Degree pain most of time-finger
HOW BAD IS THE FINGER PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C082
Degree pain most of time-chest
HOW BAD IS THE CHEST PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C083
Degree pain most of time-stomachache
HOW BAD IS THE STOMACHACHE?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C084
Degree pain most of time-waist
HOW BAD IS THE BACK PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C085
Degree pain most of time-hip
HOW BAD IS THE BUTTOCKS PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C086
Degree pain most of time-leg
HOW BAD IS THE LEG PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C087
Degree pain most of time-knee
HOW BAD IS THE KNEE PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C088
Degree pain most of time-ankle
HOW BAD IS THE ANKLE PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C089
Degree pain most of time-toe
HOW BAD IS THE TOE PAIN?
1) Mild 3) Moderate 5) Severe
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C090
Limit daily activities due to pain
DOES THE PAIN MAKE IT DIFFICULT FOR YOU TO DO DAILY ACTIVITIES?
1) yes 5) no
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C091
Other medical disease or condition
ARE THERE ANY OTHER MEDICAL DISEASES OR CONDITIONS THAT ARE IMPORTANT TO YOUR HEALTH NOW THAT WE HAVE NOT TALKED ABOUT?
1) yes 5) no
|
| |
|
|
| |
If Other medical disease or condition = 1 »
|
|
| |
|
|
| |
|
C092
name of other ilnesses
WHAT ILLNESS IS THAT? ___________________________________________________________________________
STRING
|
| |
|
|
| |
C093
Weight in Kilogram
ABOUT HOW MUCH DO YOU WEIGH? _______KILOGRAMS
30..200
|
| |
|
| |
C094
Weight gain/loss 5 Kg in LCY
HAVE YOU GAINED OR LOST 5 OR MORE KILOGRAMS IN THE LAST YEAR?
1) Yes, I gained weight 2) Yes, I lost weight 3) Yes, I gained and lost weight 4) Yes, I lost and gained weight 5) No 99) Don't know
|
| |
|
| |
C095
Height Centimeter
ABOUT HOW TALL ARE YOU? _____CENTIMETERS
70..210
|
| |
|
| |
C096
Regular exercise (more than once per week)
THE NEXT FEW QUESTIONS ARE ABOUT EXERCISE. DO YOU WORK OUT MORE THAN ONCE A WEEK?
1) yes 5) no
|
| |
|
| |
If Regular exercise (more than once per week) = 5 »
|
|
| |
|
|
| |
|
C097
Reason for not exercise regularly
WHAT IS THE MAIN REASON FOR YOU NOT BEING ABLE TO EXERCISE REGULARLY?
1) Too busy 2) No space or place to work out 3) Too lazy 4) Do not like exercise 5) Never thought about doing exercise 98) Refuse to answer
|
| |
|
|
| |
|
|
| |
|
|
| |
|
C098
Number times per week-exercise
HOW OFTEN DO YOU WORK OUT PER WEEK? ______ TIMES / PER WEEK.
1..97
|
| |
|
|
| |
|
C099
Number minutes per one-exercise
FOR HOW LONG DO YOU WORK OUT PER SESSION? ______MINUTES
1..168
|
| |
|
|
| |
|
C100
How long regular exercise
HOW LONG HAVE YOU BEEN WORKING OUT REGULARLY?
1) Less than 3 months 2) 4-6 months 3) 7 months-1 year 4) 1-2 years 5) 3-4 years 6) 5-6 years 7) More than 7 years
|
| |
|
|
| |
C101
Eating Yesterday
NOW, I AM GOING TO ASK YOU ABOUT THE MEALS YOU HAD FOR THE LAST TWO DAYS. DID YOU HAVE THREE MEALS YESTERDAY? CHOOSE ALL THAT APPLY
1) Breakfast in yesterday 2) Lunch in yesterday 3) Dinner in yesterday 4) Not had three meals in yesterday 5) Refuse to answer 6) Don't know
|
| |
|
| |
C102
Eating 2 days ago
DID YOU HAVE THREE MEALS THE DAY BEFORE YESTERDAY? CHOOSE ALL THAT APPLY
1) Breakfast in the day before yesterday 2) Lunch in the day before yesterday 3) Dinner in the day before yesterday 4) Not had three meals in the day before yesterday 5) Refuse to answer 6) Don't know
|
| |
|
| |
C103
Ever smoke (5 packs or more than 100 cigarettes)
HAVE YOU EVER SMOKED MORE THAN 5 PACKS OF CIGARETTES (100 CIGARETTES)?
1) yes 5) no 99) Don't know
|
| |
|
| |
If Ever smoke (5 packs or more than 100 cigarettes) = 1 »
|
|
| |
|
|
| |
|
C104
Smoke cigarettes now
DO YOU SMOKE CIGARETTES NOW?
1) yes 5) no 99) Don't know
|
| |
|
|
| |
|
If Smoke cigarettes now = 1 »
|
|
| |
|
|
|
| |
|
|
C105
Number cigarettes smoked per day
ABOUT HOW MANY CIGARETTES OR PACKS DO YOU USUALLY SMOKE IN A DAY NOW? _____ CIGARETTES/DAY
1..100
|
| |
|
|
|
| |
|
C106
Year/month started smoking
IN WHAT YEAR AND MONTH DID YOU FIRST START SMOKING? __________________
190000..200612
|
| |
|
|
| |
|
C107
Number cigarettes smoked per day-when smoked most
WHEN YOU WERE SMOKING THE MOST, ABOUT HOW MANY CIGARETTES OR PACKS DID YOU USUALLY SMOKE IN A DAY? _____ CIGARETTES/DAY
1..200
|
| |
|
|
| |
|
C108
Year/month stop smoking
IN WHAT YEAR AND MONTH DID YOU STOP SMOKING? _____________________
190006..200612
|
| |
|
|
| |
C109
Ever drink alcohol
DO YOU EVER DRINK ANY ALCOHOLIC BEVERAGES, SUCH AS BEER, WINE, OR LIQUOR?
1) yes 5) no
|
| |
|
| |
If Ever drink alcohol = 5 »
|
|
| |
|
|
| |
|
C110
Not drink originally alcohol
HAVE YOU NEVER HAD ALCOHOLIC BEVERAGES DUE TO SOME REASONS (E.G., RELIGIOUS, HEALTH- RELATED, ETC), OR YOU USED TO HAVE SOME DRINKS IN THE PAST?
1) No, I never had a drink 5) Yes, I used to drink
|
| |
|
|
| |
|
If Not drink originally alcohol = 5 »
|
|
| |
|
|
|
| |
|
|
C111
Drink alcohol now
DO YOU STILL DRINK?
1) Yes, I drink from time to time 5) No, I quit drinking
|
| |
|
|
|
| |
|
|
If Drink alcohol now = 1 »
|
|
| |
|
|
|
|
| |
|
|
|
C113
Year/month started drinking
WHEN DID YOU START DRINKING? _________________
190000..200612
|
| |
|
|
|
|
| |
|
|
|
C114
How long drinking alcohol
HOW MANY YEARS HAVE YOU BEEN DRINKING ALCOHOLIC BEVERAGES ALTOGETHER? IF YOU QUIT DRINKING FOR A WHILE, PLEASE DO NOT COUNT THE YEARS THAT YOU DID NOT DRINK.
1) 1-5 years 2) 6-10 years 3) 11-20 years 4) 21-30 years 5) 31-40 years 6) More than 41 years 99) Don't know
|
| |
|
|
|
|
| |
|
|
|
C115
Question about drinking frequency
NOW, I AM GOING TO ASK YOU HOW OFTEN AND HOW MUCH YOU DRINK DURING THE PAST YEAR. PLEASE TELL ME HOW OFTEN YOU DRANK PER MONTH, AND HOW MUCH YOU DRANK AT A TIME ON AVERAGE. I WILL REPEAT THE QUESTIONS FOR DIFFERENT TYPES OF ALCOHOLIC BEVERAGE.
1) CONTINUE
|
| |
|
|
|
|
| |
|
|
|
C116
How often drink per month-soju
SOJU (KOREAN LIQUOR)
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day 99) Don't know
|
| |
|
|
|
|
| |
|
|
|
If How often drink per month-soju != 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C117
How much drink at a time-soju
HOW MANY GLASSES OF SOJU DO YOU DRINK AT A TIME? (1BOTTLE=6.5 GLASSES, 1 GLASS=50CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
|
|
| |
|
|
|
C118
How often drink per month-beer
BEER
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
|
|
| |
|
|
|
If How often drink per month-beer != 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C119
How much drink at a time-beer
HOW MANY GLASSES OF BEER DO YOU DRINK AT A TIME? (1BOTTLE=2.5 MUGS, 1MUG=220CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
|
|
| |
|
|
|
C120
How often drink per month-unstrained rice wine
MAKGEOLLI (RICE WINE)
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
|
|
| |
|
|
|
If How often drink per month-unstrained rice wine != 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C121
How much drink at a time-unstrained rice wine
HOW MANY GLASSES OF MAKGEOLLI DO YOU DRINK AT A TIME? (1BOTTLE=7 GLASSES, 1 GLASS=240CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
|
|
| |
|
|
|
C122
How often drink per month-whisky or liquor
WHISKY AND OTHER LIQUORS
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
|
|
| |
|
|
|
If How often drink per month-whisky or liquor != 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C123
How much drink at a time-whisky or liquor
HOW MANY GLASSES OF WHISKY OR LIQUOR DO YOU DRINK AT A TIME? (1 BOTTLE=23 GLASSES, 1 GLASS=30CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
|
|
| |
|
|
|
C124
How often drink per month-wine
WINE
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
|
|
| |
|
|
|
If How often drink per month-wine != 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C125
How much drink at a time-wine
HOW MANY GLASSES OF WINE DO YOU DRINK AT A TIME? (1 BOTTLE=8 GLASSES, 1 GLASS=90CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
|
|
| |
|
|
|
C126
Felt need to cut down drinking
HAVE YOU EVER FELT THAT YOU SHOULD QUIT DRINKING?
1) yes 5) no
|
| |
|
|
|
|
| |
|
|
|
C127
Anyone criticize drinking
HAS ANYONE CRITICIZED YOUR DRINKING?
1) yes 5) no
|
| |
|
|
|
|
| |
|
|
|
If Anyone criticize drinking = 1 »
|
|
| |
|
|
|
|
|
| |
|
|
|
|
C128
Felt annoyed by criticism about drinking
HAVE PEOPLE EVER ANNOYED YOU BY CRITICIZING YOUR DRINKING?
1) yes 5) no
|
| |
|
|
|
|
|
| |
|
|
|
C129
Felt bad or guilty about drinking
HAVE YOU EVER FELT BAD OR GUILTY ABOUT DRINKING?
1) yes 5) no
|
| |
|
|
|
|
| |
|
|
|
C130
Ever drink in the morning
HAVE YOU EVER TAKEN A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR GET RID OF A HANGOVER?
1) yes 5) no
|
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
|
| |
|
|
|
C112
Year/month stop drinking
IN WHAT YEAR AND MONTH DID YOU QUIT DRINKING? _________________
190000..200612
|
| |
|
|
|
|
| |
|
|
|
C113
Year/month started drinking
WHEN DID YOU START DRINKING? _________________
190000..200612
|
| |
|
|
|
|
| |
|
|
|
C114
How long drinking alcohol
HOW MANY YEARS HAVE YOU BEEN DRINKING ALCOHOLIC BEVERAGES ALTOGETHER? IF YOU QUIT DRINKING FOR A WHILE, PLEASE DO NOT COUNT THE YEARS THAT YOU DID NOT DRINK.
1) 1-5 years 2) 6-10 years 3) 11-20 years 4) 21-30 years 5) 31-40 years 6) More than 41 years 99) Don't know
|
| |
|
|
|
|
| |
|
|
| |
|
|
| |
|
C113
Year/month started drinking
WHEN DID YOU START DRINKING? _________________
190000..200612
|
| |
|
|
| |
|
C114
How long drinking alcohol
HOW MANY YEARS HAVE YOU BEEN DRINKING ALCOHOLIC BEVERAGES ALTOGETHER? IF YOU QUIT DRINKING FOR A WHILE, PLEASE DO NOT COUNT THE YEARS THAT YOU DID NOT DRINK.
1) 1-5 years 2) 6-10 years 3) 11-20 years 4) 21-30 years 5) 31-40 years 6) More than 41 years 99) Don't know
|
| |
|
|
| |
|
C115
Question about drinking frequency
NOW, I AM GOING TO ASK YOU HOW OFTEN AND HOW MUCH YOU DRINK DURING THE PAST YEAR. PLEASE TELL ME HOW OFTEN YOU DRANK PER MONTH, AND HOW MUCH YOU DRANK AT A TIME ON AVERAGE. I WILL REPEAT THE QUESTIONS FOR DIFFERENT TYPES OF ALCOHOLIC BEVERAGE.
1) CONTINUE
|
| |
|
|
| |
|
C116
How often drink per month-soju
SOJU (KOREAN LIQUOR)
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day 99) Don't know
|
| |
|
|
| |
|
If How often drink per month-soju != 1 »
|
|
| |
|
|
|
| |
|
|
C117
How much drink at a time-soju
HOW MANY GLASSES OF SOJU DO YOU DRINK AT A TIME? (1BOTTLE=6.5 GLASSES, 1 GLASS=50CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
| |
|
C118
How often drink per month-beer
BEER
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
| |
|
If How often drink per month-beer != 1 »
|
|
| |
|
|
|
| |
|
|
C119
How much drink at a time-beer
HOW MANY GLASSES OF BEER DO YOU DRINK AT A TIME? (1BOTTLE=2.5 MUGS, 1MUG=220CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
| |
|
C120
How often drink per month-unstrained rice wine
MAKGEOLLI (RICE WINE)
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
| |
|
If How often drink per month-unstrained rice wine != 1 »
|
|
| |
|
|
|
| |
|
|
C121
How much drink at a time-unstrained rice wine
HOW MANY GLASSES OF MAKGEOLLI DO YOU DRINK AT A TIME? (1BOTTLE=7 GLASSES, 1 GLASS=240CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
| |
|
C122
How often drink per month-whisky or liquor
WHISKY AND OTHER LIQUORS
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
| |
|
If How often drink per month-whisky or liquor != 1 »
|
|
| |
|
|
|
| |
|
|
C123
How much drink at a time-whisky or liquor
HOW MANY GLASSES OF WHISKY OR LIQUOR DO YOU DRINK AT A TIME? (1 BOTTLE=23 GLASSES, 1 GLASS=30CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
| |
|
C124
How often drink per month-wine
WINE
1) None or less than once a month 2) Once a month 3) 2-3 times a month 4) Once a week 5) 2-3 times a week 6) 4-6 times a week 7) Once a day 8) More than twice a day
|
| |
|
|
| |
|
If How often drink per month-wine != 1 »
|
|
| |
|
|
|
| |
|
|
C125
How much drink at a time-wine
HOW MANY GLASSES OF WINE DO YOU DRINK AT A TIME? (1 BOTTLE=8 GLASSES, 1 GLASS=90CC) ______ GLASSES
1.0..100.9
|
| |
|
|
|
| |
|
C126
Felt need to cut down drinking
HAVE YOU EVER FELT THAT YOU SHOULD QUIT DRINKING?
1) yes 5) no
|
| |
|
|
| |
|
C127
Anyone criticize drinking
HAS ANYONE CRITICIZED YOUR DRINKING?
1) yes 5) no
|
| |
|
|
| |
|
If Anyone criticize drinking = 1 »
|
|
| |
|
|
|
| |
|
|
C128
Felt annoyed by criticism about drinking
HAVE PEOPLE EVER ANNOYED YOU BY CRITICIZING YOUR DRINKING?
1) yes 5) no
|
| |
|
|
|
| |
|
C129
Felt bad or guilty about drinking
HAVE YOU EVER FELT BAD OR GUILTY ABOUT DRINKING?
1) yes 5) no
|
| |
|
|
| |
|
C130
Ever drink in the morning
HAVE YOU EVER TAKEN A DRINK FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR GET RID OF A HANGOVER?
1) yes 5) no
|
| |
|
|
| |
C131
Felt depressed for two weeks or more in LCY
HAVE YOU EVER HAD FEELINGS OF BEING SAD, BLUE, OR DEPRESSED FOR TWO WEEKS OR MORE DURING THE PAST YEAR?
1) Yes 3) Did not feel depressed because I was taking anti-depressant medication 5) No
|
| |
|
| |
If Felt depressed for two weeks or more in LCY != 3 »
|
|
| |
|
|
| |
|
C132
Loss of interest in last week
NEXT I WILL ASK ABOUT HOW YOU FELT AND BEHAVED DURING THE LAST WEEK. PLEASE THINK OF HOW OFTEN YOU FELT OR BEHAVED LIKE FOLLOWINGS. DURING THE LAST WEEK, HOW OFTEN DID YOU LOSE INTEREST IN MOST THINGS?
1) Very rarely (less than one day) 2) Sometimes (1-2 days) 3) Often (3-4 days) 4) Almost always (5-7 days) 99) Don't know
|
| |
|
|
| |
|
C133
Trouble concentrating in last week
DURING THE LAST WEEK, HOW OFTEN DID YOU HAVE TROUBLE CONCENTRATING?
1) Very rarely (less than one day) 2) Sometimes (1-2 days) 3) Often (3-4 days) 4) Almost always (5-7 days) 99) Don't know
|
| |
