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BRFSS Questions

Demographics

1. What is your age?
2. Indicate sex of respondent. (Ask only if necessary.)
3. Which one of these groups would you say best represents your race?
4. Are you Hispanic or Latino?
5. How many children less than 18 years of age live in your household?
6. How many children live in your household who are less than 5 years old?
7. How many children live in your household who are 5 through 12 years old?
8. How many children live in your household who are 13 through 17 years old?
9. What is the age of the oldest child in your household under the age of 16? (M)
10. What is the age of the oldest child in your household under the age of 15?
11. What is the age of the youngest child in your household?
12. Do you have a child or children in kindergarten through 8th grade?

13. How many members of your household, including yourself, are 18 years of age or older?
14. Of the members of your household 18 years of age or older, how many are men?
15. Of the members of your household 18 years of age or older, how many are women?

16. What county do you live in?
17. What is your ZIP Code where you live?

18. What is the highest grade or year of school you completed?
19. Are you currently: (employment question)
20. Is your annual household income from all sources:
21. Are you: (marital status)

22. 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.
23. How many of these telephone numbers are residential numbers?
24. How many adult members of your household currently use a cell phone for any purpose?
25. During the past 12 months, has your household been without telephone service for 1 week or
more? Do not include interruptions of telephone service because of weather or natural disasters.

26. About how tall are you without shoes?
27. About how much do you weigh without shoes?
28. How much would you like to weigh?
29. How much did you weigh a year ago? [If you were pregnant a year ago, how much did you weigh
before your pregnancy?]
30. Was the change between your current weight and your weight a year ago intentional?

31. Which of the following best describes your residence?
32. To your knowledge, are you now pregnant?
33. 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 include training for
the Reserves or National Guard, but DOES include activation, for example, for the Persian Gulf
War.





Adult Human Papilloma Virus (HPV)

1. A vaccine to prevent the human papilloma virus or HPV infection is available and is called
cervical cancer vaccine, HPV shot, or GARDASIL. Have you EVER had the HPV vaccination?
2. How many HPV shots did you receive?

Alcohol consumption

1. During the past 30 days, how many days per week or per month did you have at least one drink of
any alcoholic beverage such as beer, wine, a malt beverage or liquor?
2. During the past month, how many days per week or per month did you drink any beer?
3. And, during the past month, about how many days per week or per month did you have any liquor
to drink, such as vodka, gin, rum or whiskey?
4. Also, during the past month, how many days per week or per month did you drink any wine?

5. [Prologue: The next question is about drinking and driving.] During the past 30 days, how many
times have you driven when you've had perhaps too much to drink?
6. During the past month, how many times have you ridden with a driver who has had perhaps too
much to drink.

7. Considering all types of alcoholic beverages, how many times during the past 30 days did you
have X [CATI X = 5 for men, X = 4 for women] or more drinks on an occasion?

8. One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a drink with one shot of
liquor. During the past 30 days, on the days when you drank, about how many drinks did you
drink on the average? (Note: A 40 ounce beer would count as 3 drinks, or a cocktail drink with 2
shots would count as 2 drinks.)
9. On the days you drank beer, about how many beers did you drink on the average?
10. On the days when you drank wine, about how many glasses of wine did you drink on the
average?
11. On the days when you drank any liquor, about how many drinks did you have on the average?
12. During the past 30 days, what is the largest number of drinks you had on any occasion?

Anxiety and Depression (all 10 questions are module questions)
1. [Prologue: Now, I am going to ask you some questions about your mood. When answering these
questions, please think about how many days each of the following has occurred in the past 2
weeks.] Over the last 2 weeks, how many days have you had little interest or pleasure in doing
things?
2. [Prologue] Over the last 2 weeks, how many days have you felt down, depressed or hopeless?
3. [Prologue] Over the last 2 weeks, how many days have you had trouble falling asleep or staying
asleep or sleeping too much?
4. [Prologue] Over the last 2 weeks, how many days have you felt tired or had little energy?
5. [Prologue] Over the last 2 weeks, how many days have you had a poor appetite or eaten too
much?
6. [Prologue] Over the last 2 weeks, how many days have you felt bad about yourself or that you
were a failure or had let yourself or your family down?
7. [Prologue] Over the last 2 weeks, how many days have you had trouble concentrating on things,
such as reading the newspaper or watching the TV?
8. [Prologue] Over the last 2 weeks, how many days have you moved or spoken so slowly that other
people could have noticed? Or the opposite--being so fidgety or restless that you were moving
around a lot more than usual?
9. [Prologue] Has a doctor or other healthcare provider EVER told you that you had an anxiety
disorder (including acute stress disorder, anxiety, generalized anxiety disorder, obsessive-
compulsive disorder, panic disorder, phobia, posttraumatic stress disorder, or social anxiety
disorder)?
10. [Prologue] Has a doctor or other healthcare provider EVER told you that you have a depressive
disorder (including depression, major depression, dysthymia, or minor depression)?

Cancer Survivors

1. [Prologue: Now I am going to ask you about cancer.] Have you EVER been told by a doctor,
nurse, or other health professional that you had cancer? (Read only if necessary: By "other health
professional" we mean a nurse practitioner, a physician's assistant, social worker, or some other
licensed professional.)
2. [Prologue] How many different types of cancer have you had?
3. [Prologue] At what age were you told that you had cancer? (Note: This question refers to the first
time they were told about their first cancer.)
4. [Prologue] What type of cancer was it? (Note: Please read list only if respondent needs prompting
for cancer type, i.e., name of cancer)

Cardiovascular disease, heart attack and stroke

1. (To lower your risk of developing heart disease or stroke, are you) more physically active? (M)
2. To lower your risk of developing heart disease or stroke, are you eating fewer high fat or high
cholesterol foods? (M)
3. (To lower your risk of developing heart disease or stroke, are you) eating more fruits and
vegetables? (M)
4. To lower your risk of developing heart disease or stroke, are you exercising more? (M)
5. [Prologue: Now I would like to ask you some questions about cardiovascular disease]. Has a
doctor, nurse, or other health professional EVER told you that you had any of the following? For
each, tell me "Yes", "No", or you're "Not sure".
a. (Ever told) you had a heart attack, also called a myocardial infarction?
b. (Ever told) you had angina or coronary heart disease?
c. (Ever told) you had a stroke?
6. At what age did you have your first heart attack? (M)
7. At what age did you have your first stroke? (M)
8. [Prologue: I would like to ask you a few questions about your cardiovascular or heart health.]
Following your heart attack, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab." (M)
9. [Prologue] Following your stroke, did you go to any kind of outpatient rehabilitation? This is
sometimes called "rehab." (M)

10. [Prologue] Do you take aspirin daily or every other day? (M)
11. [Prologue] Do you have a health problem or condition that makes taking aspirin unsafe for you?
If "Yes" ask "Is this a stomach condition?" Code upset stomach as stomach problems. (M)
12. Why do you take aspirin?
a. To relieve pain? (M)
b. To reduce the chance of a heart attack? (M)
c. To reduce the chance of a stroke? (M)
13. [Prologue: Now I would like to ask you about your knowledge of the signs and symptoms of a
heart attack and stroke. Which of the following do you think is a symptom of a heart attack? For
each, tell me "yes", "no", or you're "not sure".]
a. (Do you think) pain or discomfort in the jaw, neck, or back (are symptoms of a heart
attack?) (M)
b. (Do you think) feeling weak, lightheaded, or faint (are symptoms of a heart attack?) (M)
c. (Do you think) chest pain or discomfort (are symptoms of a heart attack?) (M)
d. (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a heart
attack?) (M)
e. (Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart
attack?) (M)
f. (Do you think) pain or discomfort in the arms or shoulder (are symptoms of a heart
attack?) (M)
g. (Do you think) shortness of breath (is a symptom of a heart attack?) (M)
14. [Prologue: Which of the following do you think is a symptom of a stroke? For each, tell me "yes",
"no", or you're "not sure".]
a. (Do you think) sudden confusion or trouble speaking (are symptoms of a stroke?) (M)
b. (Do you think) sudden numbness or weakness of face, arm, or leg, especially on one side,
(are symptoms of a stroke?) (M)
c. (Do you think) sudden trouble seeing in one or both eyes (is a symptom of a stroke?)
d. (Do you think) sudden chest pain or discomfort (are symptoms of a stroke?) (M)
e. (Do you think) sudden trouble walking, dizziness, or loss of balance (are symptoms of a
stroke?) (M)
f. (Do you think) severe headache with no known cause (is a symptom of a stroke?) (M)
15. If you thought someone was having a heart attack or a stroke, what is the first thing you would
do? (M)
16. Within the past 12 months, has a doctor, nurse, or other health professional told you to:
a. eat fewer high fat or high cholesterol foods? (M)
b. eat more fruits and vegetables? (M)
c. be more physically active? (M)

Cholesterol Awareness

1. Blood cholesterol is a fatty substance found in the blood. Have you ever had your blood
cholesterol checked?
2. About how long has it been since you last had your blood cholesterol checked?
3. Did the doctor provide you with a low fat or low cholesterol diet?
4. Did your doctor refer you to a dietician, nutritionist, or nurse to help you reduce the fat or
cholesterol in your diet?
5. Did the doctor prescribe a medication to lower your blood cholesterol?
6. What is your blood cholesterol level?
7. Are you now under the advice of a doctor to reduce your blood cholesterol or blood fat level?
8. Have you ever been told by a doctor, nurse or other health professional that your blood
cholesterol is high?
9. Have you ever been told your blood cholesterol level, in numbers?

Colorectal Cancer ---9 out of 10 are module questions
1. A blood stool test is a test that may use a special kit at home to determine whether the stool
contains blood.
a. Have you ever had this test using a home kit?
b. How long has it been since you had your last blood stool test using a home kit?
2. [Prologue: These next questions are about digital rectal exams, that is, when a doctor inserts his
finger in the rectum to check for cancer or other health problems.]
a. Have you ever heard of a digital rectal exam?
b. Have you ever had this exam?
c. When did you have your last digital rectal exam?

3. Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the rectum to view the
colon for signs of cancer or other health problems.
a. Have you ever had either of these exams?
b. How long has it been since you had your last sigmoidoscopy or colonoscopy?
4. For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for problems. A
colonoscopy is similar, but uses a longer tube, and you are usually given medication through a
needle in your arm to make you sleepy and told to have someone else drive you home after the
test. Was your MOST RECENT examination called a sigmoidoscopy or a colonoscopy?

5. A proctoscopic exam is when a tube is inserted in the rectum to check for problems.
a. Have you ever heard of a proctoscopic exam?

Pre-Diabetes (all modules)

1. Have you had a test for high blood sugar or diabetes within the past three years?
2. Have you ever been told by a doctor or other health professional that you have:
a. pre-diabetes or borderline diabetes?
i. If "Yes" and respondent is female, ask: "Was this only when you were
pregnant"?
b. Diabetes?
i. If "Yes" and respondent is female, ask: "Was this only when you were
pregnant"?

Diabetes (20 out of 21 are module questions)
1. How old were you when you were told you have diabetes?
2. 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.
3. Have you ever heard of glycosylatd hemoglobin (gli-KOS-ilated he-mo-glo-bin) or hemoglobin
"A one C"?
4. 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"?
5. About how many times in the past 12 months have you seen a doctor, nurse, or other health
professional for your diabetes?
6. 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.
7. Are you now taking insulin?
8. Currently, about how often do you use insulin?
9. 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.
10. How often do you have trouble telling the difference between a one dollar bill and a five dollar
bill? (This means when wearing glasses or contacts if needed.)
11. While stopped in a vehicle at a traffic light, how often do you have trouble reading the license
plate on the car in front of you? (This means when wearing glasses or contacts if needed.)
12. In general, how would you rate your vision when wearing glasses or contacts if needed? Would
you say:
13. I would now like to ask you three questions about how well you see with your glasses or contacts
on if you use them.
a. How much of the time does your vision limit you in watching television?
b. How much of the time does your vision limit you in recognizing people or objects across
the street?
c. How much of the time does your vision limit you in reading print in a newspaper,
magazine, recipe, menu or numbers on the telephone?
14. Are you now taking diabetes pills?
15. Have you ever taken a course or class in how to manage your diabetes yourself?
16. Have you ever had any sores or irritations on your feet that took more than four weeks to heal?
17. Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
18. About how many times in the past 12 months has a health professional checked your feet for any
sores or irritations?

Emotional support and life satisfaction

1. [Prologue: The next two questions are about emotional support and your satisfaction with life.]
How often do you get the social and emotional support you need? (Note: If asked, say "please
include support from any source.")
2. [Prologue] In general, how satisfied are you with your life?

Exercise and physical activity

1. What type of physical activity or exercise did you spend the most time doing during the past
month?
2. What other type of physical activity gave you the next most exercise during the past month?
3. During the past month, other than your regular job, did you participate in any physical activities
or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
4. Were there other activities or exercises that you participated in during the last month besides
running, calisthenics, golf, yardwork or walking for exercise?
5. How far did you usually walk/run/jog/swim (first activity)?
a. And when you took part in this activity, for how many minutes or hours did you usually
keep at it?
b. How many times per week or per month did you take part in this activity during the past
month?
c.
6. How far did you usually walk/run/jog/swim (second activity)?
a. And when you took part in this activity, for how many minutes or hours did you usually
keep at it?
b. How many times per week or per month did you take part in this activity during the past
month?

7. When you are at work, which of the following best describes what you do? Would you say-- If
respondent has multiple jobs, include all jobs.
8. [Prologue: We are interested in two types of physical activity: vigorous and moderate. Vigorous
activities cause large increases in breathing or heart rate while moderate activities cause small
increases in breathing or heart rate.]
a. Now, thinking about the moderate physical activities you do when you are not working in
a usual week, do you do moderate activities for at least 10 minutes at a time, such as brisk
walking, bicycling, vacuuming, gardening, or anything else that causes small increases in
breathing or heart rate?
b. How many days per week do you do these moderate activities for at least 10 minutes at a
time?
c. On days when you do moderate activities for at least 10 minutes at a time, how much
total time per day do you spend doing these activities?
d. Now thinking about the vigorous physical activities you do when you are not working in
a usual week, do you do vigorous activities for at least 10 minutes at a time, such as
running, aerobics, heavy yard work, or anything else that causes large increases in
breathing or heart rate?
e. How many days per week do you do these vigorous activities for at least 10 minutes at a
time?
f. On days when you do vigorous activities for at least 10 minutes at a time, how much total
time per day do you spend doing these activities?

Family planning

1. Are you currently taking birth control pills?
2. [Prologue] The next set of questions asks you about your thoughts and experiences with family
planning. Please remember that all of your answers will be kept confidential.] Some things people
do to keep from getting pregnant include not having sex at certain times, using birth control
methods such as the pill, implants, shots, condoms, diaphragm, foam, IUD, having their tubes
tied, or having a vasectomy. Are you or your [if female, insert "husband/partner", if male, insert
"wife/partner"] doing anything now to keep [if female, insert "you", if male, insert "her"] from
getting pregnant? Note: If more than one partner, consider usual partner. (module)
3. What are your reasons for not using any birth control now?
4. [Prologue] What are you or your [if female, insert 'husband/partner"; if male, insert
"wife/partner"] doing now to keep [if female, insert "you"; if male, insert "her"] from getting
pregnant? (module)
5. What other method are you also using to prevent pregnancy?
6. The next few questions ask about pregnancy and ways to prevent pregnancy. Have you been
pregnant in the last 5 years? (module)
7. Thinking back to your last pregnancy, just before you got pregnant, how did you feel about
becoming pregnant? (module)
8. Have you ever used the services at a family planning clinic? (module)
9. How long has it been since you used the services at a family planning clinic? (module)
10. Where is your usual source of services for female health concerns, such as family planning,
annual exams, breast exams, tests for sexually transmitted diseases, and other female health
concerns? (module)
11. [Prologue] How do you feel about having a child now or sometime in the future? Would you say:
(module)
12. [Prologue] How soon would you want to have a child? Would you say: (module)

Folic acid (all module questions)
1. Do you currently take any vitamin pills or supplements? Include liquid supplements.
2. Are any of these a multivitamin?
3. Do any of the vitamin pills or supplements you take contain folic acid?
4. How often do you take this vitamin pill or supplement?
5. Some health experts recommend that women take 400 micrograms of the B vitamin folic acid, for
which one of the following reasons...

Health care coverage/access

1. About how long has it been since you last visited a doctor for a routine checkup? A routine
checkup is a general physical exam, not an exam for a specific injury, illness, or condition.
2. What type of doctor did you see for your last routine checkup? Was it:
3. When you are sick or need advice about your health, to which one of the following places do you
usually go? Would you say:
4. (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?)
5. What is the main reason you do not have a usual source of medical care?
6. Do you have any kind of health care coverage, including health insurance, prepaid plans such as
HMOs, or government plans such as Medicare?
7. What type of health care coverage do you use to pay for most of your medical care? Is it coverage
through:
8. There are some types of coverage you may not have considered. Please tell me if you have any of
the following: Coverage through:
9. Other than the health coverage which pays for most of your medical care, do you have any other
type of health care coverage? (module)
10. About how long have you had this type/particular health coverage? (module)
11. Is there a book or list of doctors associated with your plan? (module)
12. Does your plan require you to select a certain doctor or clinic for all of your routine care?
(module)
13. During the past 12 months, was there any time that you did not have any health insurance or
coverage?
14. What was the main reason you were without health care coverage during the past 12 months?
(module)
15. About how long has it been since you had health care coverage? (module)
16. Previously you said that you did not have any kind of health coverage. What is the main reason
you are without health care coverage? (module)

17. For hospital bills, does your health plan cover all, most, some or none of your expenses?
18. For visits to a doctor's office when you are sick, does your health care plan cover all, most, some
or none of your expenses?
19. When you are not sick, does your health care plan cover all, most, some or none of your checkups
or other preventive services?

20. Was there a time in the past 12 months when you needed to see a doctor but could not because of
the cost?
21. Was there a time in the past 12 months when you needed medical care, but could not get it?
22. Now I am going to ask you some questions about the health care you receive. How would you
rate your satisfaction with your overall health care? (module)
23. Is there one particular doctor or health professional who you usually go to when you need routine
medical care? (module)
24. Do you have one person you think of as your personal doctor or health care provider? (If "No"
ask: "Is there more than one, or is there no person who you think of as your personal doctor or
health care provider?").

25. When did you last change doctors? (module)
26. Why did you change doctors that last time? (module)
27. Thinking of the distance or time you travel to get to the place you usually go to, how would you
rate the convenience of that place? Would you say: (module)
28. In the last 12 months,
a. how many times did you go to an emergency room to get care for yourself?(module)
b. how many times did you go to a doctor's office or clinic to get care for yourself? Would
you say: (module)
c. how often did doctors or other health providers listen carefully to you? Would you say:
(module)
d. how often did doctors or other health providers explain things in a way you could
understand? (module)
e. how often did doctors or other health providers show respect for what you had to say?
(module)
f. how often did doctors or other health providers spend enough time with you? Would you
say: (module)
29. 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? (module)
30. What is the main reason you did not get medical care? Would you say:

Health status and healthy days

1. Would you say that in general your health is---
2. 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?
3. 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?
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?

HIV/AIDS

1. These next few questions are to determine your beliefs and opinions about the national health
problem of AIDS. Have you ever heard of the AIDS virus called by the name HIV?
2. [Prologue: 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 answer every question if you do not want to. Although we will ask you about testing, we will
not ask you about the results of any test you may have had.] Have you ever been tested for HIV?
Do not count tests you may have had as part of a blood donation. Include testing fluid from your
mouth.
3. When was your last blood test for HIV?
4. Did you receive the results of your last test (HIV)?
5. Where did you have your last HIV test - at a private doctor or HMO office, at a counselling and
testing site, at a hospital, at a clinic, in a jail or prison, at a drug treatment facility, at home, or
somewhere else?
6. Did you receive counseling or talk with a health care professional about the results of your test?
7. Do you think a person can get infected with AIDS or the AIDS virus from donating blood?
8. What are your chances of getting infected with HIV, the virus that causes AIDS?
9. Has concern about AIDS changed your life in any way? (module)
10. Some people use condoms to keep from getting infected with HIV through sexual activity. How
effective do you think a properly used condom is for this purpose? Would you say: (module)
11. If you had a teenager who was sexually active, would you encourage him or her to use a condom?
12. Would you eat in a restaurant where the cook is infected with the AIDS virus?
13. Have you donated blood since March 1985?
14. When did you last donate blood?
15. The next few questions are about the national health problem of AIDS. Please remember that
your answers are strictly confidential and that you don't have to answer every question if you
don't want to. Can you tell by looking at a person if he or she has the AIDS virus?
16. Do you think a person who is infected with the AIDS virus can look and feel well and healthy?
17. Next I would like to ask you some questions about AIDS and the AIDS virus infection.
Compared to most people, how much would you say you know about AIDS? Would you say:
18. To your knowledge, is there medical treatment available that may help a person who is infected
with the AIDS virus live longer?
19. (There has been a lot of talk about how you can and cannot get infected with the AIDS virus.)
a. Do you think you can get infected from mosquitos or other insects?
b. Do you think a pregnant woman who has the AIDS virus can give it to her baby?
c. Do you think a person can get infected with AIDS or the AIDS virus from being cared for
by a nurse, doctor, dentist, or other health care worker who has the AIDS virus?
20. I am going to read you a list of reasons why some people have been tested for HIV. Not including
blood donations, which of these would you say was the MAIN reason for your last HIV test?
21. If you had a child in school, would you allow him or her to be in the same classroom with another
child who is infected with the AIDS virus?
22. Where could you go to be tested for the AIDS virus infection?
23. Have you ever personally known anyone with AIDS or the AIDS virus?

The next few questions are about the national health problem of AIDS. Please remember that your
answers are strictly confidential and that you don't have to answer every question if you don't want to.
24. Would you be willing to work next to or near a person who you know is infected with the AIDS
virus?
25. 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?
26. Have you donated blood in the past 12 months?
27. Not including your blood donations, have you been tested for HIV in the past 12 months?
28. Have you been tested for HIV in the past 12 months?
29. 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 answer
every question if you don't want to. Although we will ask about testing, we will not ask you about
the results of any test you may have had. I'm going to read two statements about HIV, the virus
that causes AIDS. After I read each one, please tell me whether you think it is true or false, or if
you don't know. A pregnant woman with HIV can get treatment to help reduce the chances that
she will pass the virus on to her baby.
30. (I am going to read two statements about HIV, the virus that causes AIDS. After I read each one,
please tell me whether you think it is true or false, or if you do not know.) There are medical
treatments available that are intended to help a person who is infected with HIV to live longer.
31. How effective do you think these treatments are helping persons with HIV to live longer? Would
you say:
32. How important do you think it is for people to know their HIV status by getting tested? Would
you say:
33. Not including blood donations, in what month and year was your last HIV test? Note: If response
is before January 1985, code "Don't know".
34. The next question is about sexually transmitted diseases other than HIV, such as syphilis,
gonorrhea, chlamydia, or genital herpes. In the past 12 months has a doctor, nurse, or other health
professional talked to you about preventing sexually transmitted diseases through condom use?
35. In the past year have your chances of getting the AIDS virus increased, decreased, or stayed the
same?
36. In the past 12 months, how many times have you been tested for HIV, including times you did not
get your results?
37. What type of clinic did you go to for your last HIV test?
38. Was this test done by a nurse or other health worker, or with a home testing kit?
39. [Prologue: I am going to read you a list. When I am done, please tell me if any of the situations
apply to you. You do not need to tell me which one.] -You have used intravenous drugs in the
past year. -You have been treated for a sexually transmitted or venereal disease in the past year. -
You have given or received money or drugs in exchange for sex in the past year. -You had anal
sex without a condom in the past year. Do any of these situations apply to you?
40. [Prologue] Was it a rapid test where you could get your results within a couple of hours?

Hypertension Awareness

1. About how long has it been since you last had your blood pressure taken by a doctor, nurse, or
other health professional? (module)
2. Have you ever been told by a doctor, nurse, or other health professional that you have high blood
pressure? (If "Yes" and respondent is female, ask "Was this only when you were pregnant?").
3. What was your blood pressure in numbers? (Blood pressure is usually given as one number over
another. Were you told what your blood pressure was in numbers?)
4. [Prologue] Is any medicine currently prescribed for your high blood pressure?
5. [Prologue] As far as you know, is your blood pressure presently normal-or under control- or is it
still high? (Note: Normal or under control includes "returned to normal" and "no longer have high
blood pressure".)
6. Next I'd like to ask you about getting your blood pressure checked. About how long has it been
since you last had your blood pressure taken by a doctor or other health professional?
7. Are you doing any of the following to help control your high blood pressure:
a. cutting down or stopping smoking?
b. Following an exercise program?
c. Following a low salt
d. specify:___________diet?
e. Avoiding stress, relaxing?
f. Watching your weight?
8. [Prologue] Have you been told on more than one occasion that your blood pressure was high, or
have you been told this only once? (module)
9. Are you currently taking medicine for your high blood pressure?

Intimate Partner Violence (all modules)

1. [Prologue: See Questionnaire] Has an intimate partner EVER THREATENED you with physical
violence? This includes threatening to hit, slap, push, kick, or physically hurt you in any way.
2. [Prologue] Has an intimate partner EVER hit, slapped, pushed, kicked, or physically hurt you in
any way?
3. [Prologue] Has an intimate partner EVER ATTEMPTED physical violence against you? This
includes times when they tried to hit, slap, push, kick, or otherwise hurt you, BUT THEY WERE
NOT ABLE TO. (Variable name change)
4. [Prologue: See questionnaire] Have you EVER experienced any unwanted sex by a current or
former intimate partner?
5. [Prologue: See Questionnaire] In the past 12 months, have you experienced any physical violence
or had unwanted sex with an intimate partner?
6. [Prologue: See Questionnaire] In the past 12 months, have you had any physical injuries, such as
bruises, cuts, scrapes, black eyes, vaginal or anal tears, or broken bones, as a result of this
physical violence or unwanted sex?
7. [Prologue: See Questionnaire] At the time of the most recent incident involving an intimate
partner who was physically violent--or--had unwanted sex with you, what was that person's
relationship to you?

Mental Illness and Stigma (all modules)

1. [Prologue: Now, I am going to ask you some questions about how you have been feeling during
the past 30 days.] About how often during the past 30 days did you feel nervous--would you say
all of the time, most of the time, some of the time, a little of the time, or none of the time?
2. [Prologue] During the past 30 days, about how often did you feel hopeless--all of the time, most
of the time, some of the time, a little of the time, or none of the time?
3. [Prologue] During the past 30 days, about how often did you feel restless or fidgety? (If
necessary: all, most, some, a little, or none of the time?)
4. [Prologue] During the past 30 days, about how often did you feel so depressed that nothing could
cheer you up? (If necessary: all, most, some, a little, or none of the time?)
5. [Prologue] During the past 30 days, about how often did you feel that everything was an effort?
(If necessary: all, most, some, a little, or none of the time?)
6. [Prologue] During the past 30 days, about how often did you feel worthless? (If necessary: all,
most, some, a little, or none of the time?)
7. [Prologue: The next question asks if any type of mental health condition or emotional problem
has recently kept you from doing your work or other usual activities.] During the past 30 days, for
about how many days did a mental health condition or emotional problem keep you from doing
your work or other usual activities? (Note: If asked, "usual activities" includes housework, self-
care, caregiving, volunteer work, attending school, studies, or recreation.)
8. [Prologue] Are you now taking medicine or receiving treatment from a doctor or other health
professional for any type of mental health condition or emotional problem?
9. [Prologue: The next questions ask about peoples' attitudes toward mental illness and its treatment.
How much do you agree or disagree with these statements about people with mental illness...]
Treatment can help people with mental illness lead normal lives. Do you--agree slightly or
strongly, or disagree slightly or strongly?
10. [Prologue] People are generally caring and sympathetic to people with mental illness. Do you--
agree slightly or strongly, or disagree slightly or strongly?

Nutrition/Diet/Fruit/Vegetables

1. [Prologue: These next questions are about the foods you usually eat or drink. Please tell me how
often you eat or drink each one, for example, twice a week, three times a month, and so forth.
Remember, I am only interested in the foods you eat. Include all foods you eat, both at home and
away from home.]
2. How often do you drink fruit juices such as orange, grapefruit, or tomato?
3. How often do you eat hot dogs or lunch meats such as ham or other cold cuts? (module)
4. How often do you usually add salt to your food at the table?
5. How often do you eat bacon or sausage? (module)
6. How often do you eat beef other than hamburger, cheeseburger, or meat loaf? (module)
7. How often do you usually add butter or margarine to bread, rolls, or vegetables? (module)
8. [Prologue] How often do you eat carrots?
9. How often do you eat cheese or cheese spreads, not including cottage cheese? (module)
10. How often do you eat doughnuts, cookies, cake, pastry or pies? (module)
11. How many eggs do you usually eat? (module)
12. How often do you eat fried chicken? (module)
13. How often do you eat french fries or fried potatoes? (module)
14. [Prologue] How often do you eat green salad?
15. How often do you eat hamburgers, cheesburgers, or meat loaf? (module)
16. [Prologue] Not counting juice, how often do you eat fruit?
17. How often do you eat pork other than ham, bacon, or sausage? (module)
18. [Prologue] How often do you eat potatoes not including French fries, fried potatoes, or potato
chips?
19. How often to you usually eat snacks, such as chips or popcorn? (module)
20. [Prologue] Not counting carrots, potatoes, or salad, how many servings of vegetables do you
usually eat? (Example: A serving of vegetables at both lunch and dinner would be two servings.)
21. Overall, would you say your diet is high, medium, or low in fat?
22. Overall, would you say your diet is high, medium or low in fiber?
23. How many glasses (8oz.) 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.
(module)
24. Including breakfast, lunch and dinner, how many days per week, if any, do you eat red meat such
as beef, pork, hamburger or sausage but not including chicken or fish?

Oral Health

1. Do you have any kind of insurance coverage that pays for some or all of your routine dental care,
including dental insurance, prepaid plans such as HMOs, or government plans such as Medicaid?
(module)
2. How long has it been since you last visited a dentist or a dental clinic for any reason? Include
visits to dental specialists, such as orthodontists.
3. How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
4. What is the main reason you have not visited the dentist in the last year? (module)
5. How many of your permanent teeth have been removed because of tooth decay or gum disease?
Include teeth lost to infection, but do not include teeth lost for other reasons, such as injury or
orthodontics. (Note: If wisdom teeth are removed because of tooth decay or gum disease, they
should be included in the count for lost teeth.)

Osteoporosis

1. [Prologue: Osteoporosis is a condition where bones become brittle and break (fracture) more
easily. It is not the same condition as osteoarthritis, a joint disease.] Have you ever been told by a
doctor, nurse, or other health professional that you have osteoporosis? (module)

Preventive Counseling Services (all modules)

1. The next series of questions is about counseling services related to prevention that you might
have received from a doctor, nurse, or other health professional.
2. Has a doctor or other health professional ever talked with you
a. About your diet or eating habits?
b. About physical activity or exercise?
c. about injury prevention, such as safety belt use, helmet use, or smoke detectors?
d. about drug abuse?
e. about alcohol use?
f. ever advised you to quit smoking?
g. ever talked with you about your sexual practices, including family planning, sexually
transmitted diseases, AIDS, or the use of condoms?

Quality of Life (13 modules/2 core)

1. [Prologue: The following questions are about health problems or impairments you may have.]
Are you limited in any way in any activities because of physical, mental, or emotional problems?
(core)
2. For how long have your activities been limited because of your major impairment or health
problem?
3. [Prologue: The next few questions are about health-related problems or symptoms.] 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?
4. Because of any impairment or health problem,
a. do you need the help of other persons with your personal care needs, such as eating,
bathing, dressing, or getting around the house?
b. 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?
5. [Prologue] During the past 30 days, for about how many days have you
a. felt sad, blue, or depressed? (Screened for physical, mental, emotional problems or use of
special equipment because of a health problem.)
b. felt worried, tense, or anxious? (Screened for physical, mental, emotional problems or use
of special equipment because of a health problem.)
c. felt you did not get enough rest or sleep? (Screened for physical, mental, emotional
problems or use of special equipment because of a health problem.)
d. felt very healthy and full of energy? (Screened for physical, mental, emotional problems
or use of special equipment because of a health problem.)
6. [Prologue] 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. (core)
7. What is your major impairment or health problem?

Sexual Behavior (11 module/2 core)

1. Did you make any of the following changes in the past 12 months?...
a. Did you decrease the number of your sexual partners or become abstinent?
b. Do you now have sexual intercourse with only the same partner?
2. Due to what you know about HIV, have you changed your sexual behavior in the past 12 months?
3. These next few questions are about your personal behavior, and I want to remind you that your
answers are confidential. During the past 12 months, with how many people have you had sexual
intercourse? (core)
4. During the last week, how many times have you had sexual intercourse?
5. Was a condom used the last time you had sexual intercourse?
6. The last time you had sexual intercourse, was the condom used...
7. I'm going to read you a list. When I'm done, please tell me if any of the situations apply to you.
You don't need to tell me which one. You have used intravenous drugs in the past year. You have
been treated for a sexually transmitted or venereal disease in the past year. You have given or
received money or drugs in exchange for sex in the past year. You had anal sex without a condom
in the past year. Do any of these situations apply to you? (core)
8. In the past five years, have you been treated for a sexually transmitted or venereal disease?
9. Were you treated at a health department STD clinic?
10. How many new sex partners did you have during the past twelve months?
11. (Did you make the following change in the past 12 months?...) Do you now always use condoms
for protection?
12. Some people use condoms to keep from getting infected with HIV through sexual activity. How
effective do you think a properly use condom is for this purpose?

Sexual Violence (all modules)

1. [Prologue] In the past 12 months, has anyone exposed you to unwanted sexual situations that did
not involve physical touching? Examples include things like sexual harassment, someone
exposing sexual parts of their body to you, being seen by a peeping Tom, or someone making you
look at sexual photos or movies?
2. [Prologue: My first questions are about unwanted sexual experiences you may have had.] In the
past 12 months, has anyone touched sexual parts of your body after you said or showed that you
didn't want them to or without your consent (for example being groped or fondled)?
3. [Prologue: See Questionnaire] In the past 12 months, has anyone ATTEMPTED to have sex with
you after you said or showed that you didn't want to or without your consent, BUT SEX DID
NOT OCCUR?
4. [Prologue: See Questionnaire] In the past 12 months, has anyone HAD SEX with you after you
said or showed that you didn't want to or without your consent?
5. [Prologue] Think about the time of the most recent incident involving a person who had sex with
you -or- attempted to have sex with you after you said or showed that you didn't want to or
without your consent? What was that person's relationship to you?
6. [Prologue: See Questionnaire] Was the person who did this male or female?
7. [Prologue: See Questionnaire] Has anyone EVER ATTEMPTED to have sex with you after you
said or showed that you didn't want to or without your consent, BUT SEX DID NOT OCCUR?
8. [Prologue: See Questionnaire] Has anyone EVER had sex with you after you said or showed that
you didn't want them to or without your consent?
9. [Prologue: Now I'd like to ask you some questions about different types of physical and/or sexual
violence or other unwanted sexual experiences. This information will allow us to better
understand the problem of violence and unwanted sexual contact may help others in the future.
This is a sensitive topic. Some people may feel uncomfortable with these questions. At the end of
this section, I will give you phone numbers for organizations that can provide information and
referral for these issues. Please keep in mind that if you are not in a safe place you can ask me to
skip any question you do not want to answer.] Are you in a safe place to answer these questions?
10. [Prologue] Has this happened in the past 12 months? (Anyone ever had sex with you after you
said or showed that you didn't want them to or without your consent.)
11. [Prologue] Has this happened in the past 12 months? (Anyone ever attempted to have sex with
you after you said or showed that you didn't want to or without your consent, but sex did not
occur.)

Social Context (all modules)

1. These next questions are about your daily life. How safe from crime do you consider your
neighborhood to be?
2. [Prologue: There are many different factors that can affect a person's health. I'm going to ask you
about several factors that can affect a person's health.] Do you own or rent your home? (Note:
"Other arrangement" may include group home or staying with friends or family without paying
rent.)
3. How long have you lived at your current address?
4. How many close friends or relatives would help you with your emotional problems or feelings if
you needed it?
5. In the past 30 days, have you been concerned about having enough food for you or your family?
6. [Prologue] How often in the past 12 months would you say you were worried or stressed about
7. having enough money to pay your rent/mortgage? Would you say you were worried or
stressed---
a. having enough money to buy nutritious meals? Would you say you were worried or
stressed---
8. [Prologue] At your main job or business, how are you generally paid for the work you do? Are
you: (Note: If paid in multiple ways at their main job, select option 4 (Paid some other way.)
9. [Prologue] About how many hours do you work per week at all of your jobs and businesses
combined?
10. [Prologue] Thinking about the last time you worked, at your main job or business, how were you
generally paid for the work you do? Were you:
11. [Prologue] Thinking about the last time you worked, about how many hours did you work per
week at all of your jobs and businesses combined?
12. [Prologue] Did you vote in the last presidential election? The November 2008 election between
Barack Obama and John McCain?

Tobacco Use

1. About how old were you when you first started smoking cigarettes fairly regularly?
2. Do you think smokeless tobacco can cause any of the following:
a. Cancer of the mouth?
b. Gum disease or mouth sores?
c. Tooth decay?
d. Stained teeth?
3. How long has it been since you last smoked cigarettes regularly?
4. About how long has it been since you last smoked cigarettes fairly regularly? Was it:
5. Would you like to stop smoking?
6. How long did you actually stay off cigarettes that time?
7. Have you smoked at least 100 cigarettes in your entire life? [Note: 5 packs = 100 cigarettes]
8. On how many of the past 30 days did you smoke cigarettes?
9. Do you smoke cigarettes now?
10. On the average, about how many cigarettes a day do you now smoke?
11. On the average, when you smoked during the past 30 days, about how many cigarettes did you
smoke a day?
12. Have you stopped smoking for a week or more sometime during the past year?
13. During the past 12 months, have you stopped smoking for one day or longer because you were
trying to quit smoking?
14. Prologue: Now, I would like to ask you questions about your use of tobacco products other than
cigarettes.] Have you ever used or tried any smokeless tobacco products such as chewing tobacco,
snuff, or snus? (Snus rhymes with goose)[Note: Snus (Swedish for snuff) is a moist smokeless
tobacco, usually sold in small pouches that is placed under the lip against the gum.] (module)
15. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all? Note:
Snus (Swedish for snuff) is a moist smokeless tobacco, usually sold in small pouches that are
placed under the lip against the gum.
16. Have you stopped using smokeless tobacco for a week or more sometime during the past year?
17. For how long have you been using/did you use smokeless tobacco?
18. When was the start of your most recent (smoking) quit attempt?
19. Do you now smoke cigarettes every day, some days, or not at all?
20. Have you ever smoked a cigar, even one or two puffs?
21. When was the last time you smoked a cigar?
22. In the past month, did you smoke cigars:
23. While working at your job, are you indoors most of the time? (module)
24. Which of the following best describes your place of work's official smoking policy for indoor
public or common areas, such as lobbies, rest rooms, and lunch rooms? Note: For workers who
visit clients, "place of work" means their location. For self-employed persons who work at home,
the official smoking policy means the home smoking policy. (module)
25. Which of the following best describes your place of work's official smoking policy for work
areas? (module)
26. In the following locations, do you think that smoking should be allowed in all areas, some areas,
or not allowed at all?
a. In restaurants, (do you think that smoking should be allowed in all areas, some areas, or
not allowed at all?) (module)
b. In schools, do you think that smoking should be allowed in all areas, some areas, or not
allowed at all? (module)
c. In day care centers, do you think that smoking should be allowed in all areas, some areas,
or not allowed at all? (module)
d. In indoor work areas, do you think that smoking should be allowed in all areas, some
areas, or not allowed at all? (module)
27. Do you think that billboards that advertise tobacco products should be allowed near places
frequented by children, such as schools, playgrounds, and churches? (module)
28. In the past 30 days has anyone, including yourself, smoked cigarettes, cigars, or pipes anywhere
inside your home? (module)
29. In the past 12 months, has a doctor, nurse, or other health professional advised you to quit
smoking? (module)
30. Previously you said you have smoked cigarettes. How old were you the first time you smoked a
cigarette, even one or two puffs? (module)
31. How old were you when you first started smoking cigarettes regularly? (module)
32. In the past 12 months, have you seen a doctor, nurse, or other health professional to get any kind
of care for yourself? (module)
33. [Prologue] Which statement best describes the rules about smoking inside your home? Do not
include decks, garages, or porches. (module)
34. Do you now smoke cigars every day, some days, or not at all? (module)
35. Have you ever smoked tobacco in a pipe, even one or two puffs? (module)
36. Do you now smoke a pipe every day, some days, or not at all? (module)
37. A bidi is a flavored cigarette from India. Have you ever smoked a bidi, even one or two puffs?
(module)
38. Do you now smoke bidis every day, some days, or not at all? (module)
39. [Prologue] Do you currently cigars, pipes, bidis, kreteks, or any other tobacco product? Do not
include cigarettes, snus, snuff, or chewing tobacco. (Note: Bidis are small, brown, hand-rolled
cigarettes from India and other southeast Asian countries. Kreteks are clove cigarettes made in
Indonesia that contain clove extract and tobacco.) (module)
40. [Prologue: The next questions are about interactions you might have had with a doctor, nurse, or
other health professional.] In the past 12 months, how many times have you seen a doctor, nurse
or other health professional to get any kind of care for yourself? (module)
41. [Prologue] In the past 12 months, on how many visits were you advised to quit smoking by a
doctor or other health provider? (module)
42. [Prologue] On how many visits did your doctor, nurse or other health professional recommend or
discuss
a. medication to assist you with quitting smoking, such as nicotine gum, patch, nasal spray,
inhaler, lozenge, or prescription medication such as Wellbutrin/Zyban/Buproprion?
(module)
b. methods and strategies other than medication to assist you with quitting smoking?
(module)
43. [Prologue: The next questions are about exposure to secondhand smoke.] On how many of the
past 7 days, did someone smoke in your indoor workplace while you were there? (module)
44. [Prologue] On how many of the past 7 days, did anyone smoke in your home while you were
there? (module)
45. [Prologue] In bars, do you THINK smoking should be allowed in all areas, some areas or not
allowed at all? (module)
46. [Prologue] In restaurants, do you THINK smoking should be allowed in all areas, some areas or
not allowed at all? (module)
47. [Prologue] Inside indoor workplaces, do you THINK smoking should be allowed in all areas,
some areas or not allowed at all? (module)

Visual impairment and access to eye care (all modules)

1. [Prologue: Now, I would like to ask you questions about your vision. These questions are for all
respondents regardless of whether or not you wear glasses or contact lenses. If you wear glasses
or contact lenses, answer questions as if you are wearing them.]
2. How much difficulty, if any, do you have
a. in recognizing a friend across the street? Would you say--
b. watching television? Would you say--
c. reading print in newspapers, magazines, recipes, menus, or numbers on the telephone?
Would you say--
3. [Prologue] When was the last time you visited ANY eye care professional?
4. [Prologue] What is the main reason you have not visited an eye care professional in the past 12
months? (Variable name change)
5. [Prologue] 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?
6. [Prologue] Do you have any kind of health insurance coverage for eye care?
7. [Prologue] Have you been told by an eye doctor or other health care professional that you NOW
have cataracts?
8. [Prologue] Have you EVER been told by an eye doctor or other health care professional that you
had glaucoma?
9. [Prologue: Age-related Macular Degeneration (AMD) is a disease that affects the macula, the part
of the eye that allows you to see fine detail.] Have you EVER been told by an eye doctor or other
health care professional that you had age-related macular degeneration?
10. [Prologue] Have you EVER had an eye injury that occurred at your workplace while you were
doing your work?
11. About how many days did this injury cause you to miss work?
12. [Prologue] When was the last time you had your eyes examined by any doctor or eye care
provider?

Weight Control (14 module/3 core)

1. Some people count calories. If you are counting calories, about how many calories are you eating
per day?
2. About how long have you been eating this many calories per day?
3. Do you now consider yourself to be overweight, underweight, or about average?
4. In the past two years, have you taken any weight loss pills prescribed by a doctor? Do not include
water pills or thyroid medications. (core)
5. In the past 12 months, has a doctor, nurse or other health professional given you advice about
your weight?
6. Are you now doing any of the following to lose weight or to keep from gaining weight: fasting
for 24 hours or longer as part of your diet?
7. Are you eating fewer calories or less fat to lose weight, or to keep from gaining weight?
8. Are you now trying to lose weight?

9. Are you now trying to maintain your current weight, that is to keep from gaining weight?

10. Are you using physical activity or exercise to lose weight or to keep from gaining weight?
11. Are you now doing any of the following to lose weight or to keep from gaining weight:
a. participating in an organized weight control program (such as Weight Watchers, TOPS,
or Nutri-Systems)?
b. taking special products such as canned or powdered supplements?
c. causing yourself to vomit after your eat?

12. About how long ago did you begin your current attempt to lose weight?
13. Are you now doing any of the following to lose weight or to keep from gaining weight: How
much did you weigh just before you started taking prescription weight loss pills for the first time?
(core)
14. How much would you like to weigh?
15. How much weight, if any, have you lost since beginning your diet? (core)


Womens Health (21 modules/6 core)

1. Do you know how to examine your own breasts for lumps?
2. [Prologue] Have you had a hysterectomy? A hysterectomy is an operation to remove the uterus
(womb).
3. [Prologue: The next questions are about breast and cervival cancer.] A mammogram is an x-ray
of each breast to look for breast cancer. Have you ever had a mammogram?
4. [Prologue] A Pap test is a test for cancer of the cervix. Have you ever had a Pap test?
5. Whose idea was it for you to have this last mammogram - was it your idea, your doctor's idea, or
someone else's idea? (core)
6. These next questions are about mammograms which are x-ray tests of the breast to look for
cancer. Have you ever heard of a mammogram?
7. What is the most important reason that you did not have a mammogram in the last year? [This
question is repeated - check pathway of questionnaire (questions 60a & 60b of 1989, questions
50a & 50b of 1990)] (core)
8. These next questions are about Pap smears, which test for cancer of the cervix or uterus. Have
you ever heard of a Pap smear test? (core)
9. To your knowledge, are you now pregnant? (core)
10. During what month is your baby due? (core)
11. [Prologue] How long has it been since you had your last mammogram?
12. [Prologue] How long has it been since you had your last Pap test?
13. [Prologue] How long has it been since your last breast exam?
14. About how many mammograms have you had in the last five years? (core)
15. [Prologue] A clinical breast exam is when a doctor, nurse, or other health professional feels the
breasts for lumps. Have you ever had a clinical breast exam?
16. 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?
17. Were either of your two most recent mammograms done to check a possible problem? -or- Was
your most recent mammogram done to check a possible problem?
18. About how often do you examine your breasts for lumps?
19. Was your last Pap smear done as part of a routine exam or to check a current or previous
problem?
20. The next few questions are about menopause, or what some women refer to as the "change of
life." Have you gone through or are you now going through menopause?
21. 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. Has your
doctor discussed the benefits and risks of estrogen with you?
22. Other than birth control pills, has your doctor ever prescribed estrogen pills for you?
23. Are you currently taking estrogen pills?
24. Why are you taking or did you take estrogen pills?
a. To prevent a heart attack?
b. To treat or prevent bone thinning, bone loss, or osteoporosis?
c. To treat symptoms of menopause such as hot flashes?
25. You said your most recent mammogram was [CATI will be used to insert the time frame from the
question "How long has it been since you had your last mammogram?"]. How long before THAT
mammogram was the last one?