Final draft of 98 core questionnaire & modules

BRFSS 1998 Questionnaire Form A
Would you say that in general your health is: Do not read
these responses
Now thinking about your physical health, which includes physical illness and injury, for howmany days during the past 30 days was your physical health not good? (36-37) Now thinking about your mental health, which includes stress, depression, and problemswith emotions, for how many days during the past 30 days was your mental health not good?(38-39) None If Q2 also "None," go to Q5
During the past 30 days, for about how many days did poor physical or mental health keepyou from doing your usual activities, such as self-care, work, or recreation? Do you have any kind of health care coverage, including health insurance, prepaid planssuch as HMOs, or government plans such as Medicare? No Go to Q7a
Don't know/Not sure Go to Q10
Refused Go to Q10
Medicare is a coverage plan for people 65 or over and for certain disabled people. Do youhave Medicare? Yes Go to Q10
What type of health care coverage do you use to pay for most of your medical care?(44-45)
Is it coverage through:
01 Your employer Go to Q8
02 Someone else’s employer Go to Q8
03
A plan that you or someone else buys on your own Go to Q8
04 Medicare Go to Q10
05 Medicaid or Medical Assistance [or substitute state program name] Go to Q8
06 The military, CHAMPUS, TriCare, or the VA [or CHAMP-VA] Go to Q8
07 The Indian Health Service [or the Alaska Native Health Service] Go to Q8 or
08 Some other source Go to Q8
Do not read
None Go to Q9
Don't know/Not sure Go to Q8
responses
Refused Go to Q8
There are some types of coverage you may not have considered. Please tell me if you haveany of the following? Is it coverage through: If more than
"Which type
03 A plan that you or someone else buys on your own do you use to 04 Medicare Go to Q10
pay for most
05 Medicaid or Medical Assistance [or substitute state program name]
06 The military, CHAMPUS, TriCare, or the VA [or CHAMP-VA]
07 The Indian Health Service [or the Alaska Native Health Service] or
care?"
None Go to Q9
read these
Don't know/Not sure Go to Q10
responses
Refused Go to Q10
During the past 12 months, was there any time that you did not have any health insurance orcoverage? Yes Go to Q10
No Go to Q10
Don't know/Not sure Go to Q10
Refused Go to Q10
8b. What was the main reason you were without health care coverage during the past 12 01 Lost job or changed employers
02 Spouse or parent lost job or changed employers [includes any
person who had been providing insurance prior to job loss or change]
Became ineligible because of age or because left school Employer doesn’t offer or stopped offering coverage 07 Cut back to part time or became temporary employee08 Benefits from employer or former employer ran out 09 Couldn't afford to pay the premiums10 Insurance company refused coverage11 Lost Medicaid or Medical Assistance eligibility87 Other77 About how long has it been since you had health care coverage? Within the past 6 months (1 to 6 months ago) Within the past year (6 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 5 years (2 to 5 years ago) Was there a time during the last 12 months when you needed to see a doctor, but could notbecause of the cost? About how long has it been since you last visited a doctor for a routine checkup? (51) A routine checkup 1
Within the past year (1 to 12 months ago) is a general
Within the past 2 years (1 to 2 years ago) physical exam,
Within the past 5 years (2 to 5 years ago) not an exam for
a specific injury,
illness, or
condition
11b. Is there one particular clinic, health center, doctor's office, or other place that you usually go to if you are sick or need advice about your health? Yes Go to Q12
More than one place Go to Q11c and code 01
Don't know/Not sure Go to Q. 12
Refused Go to Q. 12
11c. What is the main reason you do not have a usual source of medical care? No place is available/close enough/convenient Have you ever been told by a doctor that you have diabetes? If "Yes" and
female, ask
Yes, but female told only during pregnancy Go to Q. 13
"Was this
No Go to Q. 13
only when
Don't know/Not sure Go to Q. 13
Refused Go to Q. 13
pregnant?"
12b. How old were you when you were told you have diabetes? Code age in years [76 = 76 and older]
No Go to Q12e
Refused Go to Q12e
12d. Currently, about how often do you use insulin? 12e. 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 healthprofessional.
12f. Have you ever heard of glycosylated hemoglobin [gli-KOS-ilated HE-mo-glo-bin] or No Go to Q12h
Don't know/Not sure Go to Q12h
Refused Go to Q12h
12g. About how many times in the last year has a doctor, nurse, or other health professional checked you for glycosylated hemoglobin or hemoglobin "A one C"? 12h. About how many times in the last year have you seen a doctor, nurse, or other health 12i. About how many times in the last year has a health professional checked your feet for any 12j. 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.
Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) The next few questions are about exercise, recreation, or physical activities other than yourregular job duties.
During the past month, did you participate in any physical activities or exercises such asrunning, calisthenics, golf, gardening, or walking for exercise? No Go to Q23
Don't know/Not sure Go to Q23
Refused Go to Q23
What type of physical activity or exercise did you spend the most time doing during the pastmonth? Activity (specify): _________________________ Refused Go to Q18
Ask Q15 only if answer to Q14 is running, jogging, walking, or swimming. All others, go to Q16.
How far did you usually walk/run/jog/swim? __ __.__ Miles and tenths7 7 7 Don't know/Not sure9 9 9 Refused How many times per week or per month did you take part in this activity during the pastmonth? 1 __ __ Times per week2 __ __ Times per month7 7 7 And when you took part in this activity, for how many minutes or hours did you usually keepat it? Was there another physical activity or exercise that you participated in during the lastmonth? No Go to Q23
Don't know/Not sure Go to Q23
Refused Go to Q23
What other type of physical activity gave you the next most exercise during the past month? Activity (specify): __________________________ Refused Go to Q23
Ask Q20 only if answer to Q19 is running, jogging, walking, or swimming. All others go to Q21.
How far did you usually walk/run/jog/swim? How many times per week or per month did you take part in this activity? And when you took part in this activity, for how many minutes or hours did you usually keepat it? Have you smoked at least 100 cigarettes in your entire life? No Go to Q28
Don't know/Not sure Go to Q28
Refused Go to Q28
Do you now smoke cigarettes everyday, some days, or not at all? Some days Go to Q25a
Not at all Go to Q27
Refused Go to Q28
On the average, about how many cigarettes a day do you now smoke? 1 pack = 20
Number of cigarettes [76 = 76 or more] Go to Q26
cigarettes
7 7 Don't know/Not sure Go to Q26
9 9 Refused Go to Q26
25a. On the average, when you smoked during the past 30 days, about how many cigarettes did 1 pack = 20
Number of cigarettes [76 = 76 or more] Go to Q28
cigarettes
7 7 Don't know/Not sure Go to Q28
9 9 Refused Go to Q28
During the past 12 months, have you quit smoking for 1 day or longer? Yes Go to Q28
No Go to Q28
Don't know/Not sure Go to Q28
Refused Go to Q28
About how long has it been since you last smoked cigarettes regularly, that is, daily?(84-85) 0 1 Within the past month (0 to 1 month ago)0 2 Within the past 3 months (1 to 3 months ago)0 3 Within the past 6 months (3 to 6 months ago)0 4 Within the past year (6 to 12 months ago)0 5 Within the past 5 years (1 to 5 years ago)0 6 Within the past 15 years (5 to 15 years ago)0 7 15 or more years ago7 7 28. Have you ever smoked a cigar, even just a few puffs? No Go to Question 31
Don’t know/Not sure Go to Question 31
Refused Go to Question 31
29. When was the last time you smoked a cigar? Within the past 3 months (1 to 3 months ago) Go to Question 31
Within the past 6 months (3 to 6 months ago) Go to Question 31
Within the past year (6 to 12 months ago) Go to Question 31
Within the past 5 years (1-5 years ago) Go to Question 31
Within the past 15 years (5-15 years ago) Go to Question 31
15 or more years ago Go to Question 31
Don’t know/not sure Go to Question 31
Refused Go to Question 31
30. In the past month, did you smoke cigars: Once per week or
These next questions are about the foods you usually eat or drink. Please tell me how often youeat or drink each one, for example, twice a week, three times a month, and so forth. Remember, Iam only interested in the foods you eat. Include all foods you eat, both at home and away fromhome.
How often do you drink fruit juices such as orange, grapefruit, or tomato? Not counting juice, how often do you eat fruit? How often do you eat potatoes not including french fries, fried potatoes, or potato chips? 1 Per day Not counting carrots, potatoes, or salad, how many servings of vegetables do you usuallyeat? Yes Go to Q39
Are you now trying to maintain your current weight, that is to keep from gaining weight? 1Yes No Go to Q41
Don't know/Not sure Go to Q41
Refused Go to Q41
Are you eating either fewer calories or less fat to.
lose weight? [if "Yes" on Q37]
keep from gaining weight? [if "Yes" on Q38]
Probe for
Are you using physical activity or exercise to.
lose weight? [if "Yes" on Q37]
keep from gaining weight? [if "Yes" on Q38]
In the past 12 months, has a doctor, nurse, or other health professional given you adviceabout your weight? Probe for
In the past two years, have you taken any weight loss pills prescribed by a doctor? Do notinclude water pills or thyroid medications.
Include only
pills taken for
Yes, I have taken them but I am not currently taking them the primary
No, I have not taken them Go to Q44
purpose of
Don’t know/Not sure Go to Q44
losing weight
Refused Go to Q44
Probe for which
How much did you weigh just before you started taking prescription weight loss pills for thefirst time? fractions
American Indian, Alaska Native or
Never been married or
How many children live in your household who are.
7 = 7 or more _ _
9 = Refused
What is the highest grade or year of school you completed? Never attended school or only kindergarten College 1 year to 3 years (Some college or technical school) College 4 years or more (College graduate) Retired or
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 $35,000 ($25,000 to less than $35,000) Less than $50,000 ($35,000 to less than $50,000) About how much do you weigh without shoes? Do you have more than one telephone number in your household? No Go to Q57b
Refused Go to Q57b
How many residential telephone numbers do you have? Exclude dedicated
Total telephone numbers [8 = 8 or more]
fax and computer
57b. During the past year, have you been without telephone service for two or more weeks? A mammogram is an x-ray of each breast to look for breast cancer. Have you ever had amammogram? No Go to Q62
Don't know/Not sure Go to Q62
Refused Go to Q62
How long has it been since you had your last mammogram? Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 3 years (2 to 3 years ago) Within the past 5 years (3 to 5 years ago) Was your last mammogram done as part of a routine checkup, because of a breast problemother than cancer, or because you've already had breast cancer? A clinical breast exam is when a doctor, nurse, or other health professional feels the breastfor lumps. Have you ever had a clinical breast exam? No Go to Q65
Don't know/Not sure Go to Q65
Refused Go to Q65
How long has it been since your last breast exam? Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 3 years (2 to 3 years ago) Within the past 5 years (3 to 5 years ago) Was your last breast exam done as part of a routine checkup, because of a breast problemother than cancer, or because you've already had breast cancer? A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear? (150)1 No Go to Q68
Don't know/Not sure Go to Q68
Refused Go to Q68
How long has it been since you had your last Pap smear? Within the past year (1 to 12 months ago) Within the past 2 years (1 to 2 years ago) Within the past 3 years (2 to 3 years ago) Within the past 5 years (3 to 5 years ago) Was your last Pap smear done as part of a routine exam, or to check a current or previousproblem? A hysterectomy
Yes Go to Q. 68c
is an operation
No If respondent is <45 years old, go to Q. 69
to remove the
Don't know/Not sure If respondent is <45 years old, go to Q. 69
uterus (womb) 9
Refused If respondent is <45 years old, go to Q. 69
68b. Have you gone through or are you now going through menopause? for which
68c. Estrogens such as Premarin and progestins such as Provera are female hormones that may be prescribed around the time of menopause, after menopause, or after a hysterectomy. Hasyour doctor discussed the benefits and risks of estrogen with you? 68d. Other than birth control pills, has your doctor ever prescribed estrogen pills for you? (400) No If <65 years old, go to Q 70, if 65+, go to closing
estrogen
Don't know/Not sure No If <65 years old, go to Q 70, if 65+, go to closing.
Refused No If <65 years old, go to Q 70, if 65+, go to closing.
68e. Are you currently taking estrogen pills? estrogen
Don't know/Not sure No If <65 years old, go to Q 70, if 65+, go to closing.
Refused No If <65 years old, go to Q 70, if 65+, go to closing.
are you taking.[if "Yes" to Q68e]
did you take.[if "No" to Q68e]
Please Read
68g. To treat or prevent bone thinning, bone loss, or osteoporosis If respondent 45 years old or older OR answered yes to Q. 68, Go to Question 70 or to
closing if 65+.
If respondent is 65 years old or older, go to Closing Statement.
The next few questions are about the national health problem of HIV, the virus that causes AIDS. Please remember that your answers are strictly confidential and that you don't have to answerevery question if you don't want to.
If you had a child in school, at what grade do you think he or she should begin receivingeducation in school about HIV infection and AIDS? through 12
5 5 Kindergarten8 8 Never7 7 Don't know/Not sure9 9 Refused If you had a teenager who was sexually active, would you encourage him or her to use acondom? What are your chances of getting infected with HIV, the virus that causes AIDS? Not applicable (already infected) Go to Q76b
No Go to Q75a
Don't know/Not sure Go to Q75a
Refused Go to Q75a
Code month and year Go to Q75
7 7 7 7 Don’t know/Not sure Go to Q75
Refused Go to Q75
Except for tests you may have had as part of blood donations, have you ever been tested forHIV? Yes Go to Q76b
saliva tests
No Go to Closing Statement
Don’t know/Not sure Go to Closing Statement
Refused Go to Closing Statement
Yes Go to Q76b
saliva tests
No Go to Closing Statement
Don’t know/Not sure Go to Closing Statement
Refused Go to Closing Statement
saliva tests
What was the main reason you had your last test for HIV? For hospitalization or surgical procedure For military induction or military service Because it was part of a blood donation process Go to Closing Statement
Where did you have your last test for HIV? Hospital, emergency room, outpatient clinic Military induction or military service site At home, home visit by nurse or health worker Did you receive the results of your last test? No Go to Closing Statement
Don't know/Not sure Go to Closing Statement
Refused Go to Closing Statement
Did you receive counseling or talk with a health care professional about the results of yourtest?

Source: http://app.idph.state.il.us/brfss/ques/1998formA.pdf