Preventive Care (AP) Section
AP01
====
OMITTED.
AP02
====
OMITTED.
AP03
====
OMITTED.
AP04
====
OMITTED.
AP04A
=====
OMITTED.
AP05
====
OMITTED.
AP06
====
OMITTED.
AP07
====
OMITTED.
AP08
====
OMITTED.
AP09
====
OMITTED.
AP10
====
OMITTED.
AP11
====
OMITTED.
AP11A
=====
OMITTED.
AP11B
=====
OMITTED.
AP11C
=====
OMITTED.
BOX_01
======
OMITTED.
AP12
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
The next few questions ask about the amounts and types of
preventive care (PERSON) may receive.
On average, how often (do/does) (PERSON) receive a dental
check-up?
TWICE A YEAR OR MORE ................... 1
ONCE A YEAR ............................ 2
LESS THAN ONCE A YEAR .................. 3
NEVER GO TO DENTIST .................... 4
REF ................................... -7
DK .................................... -8
[Code One]
PRESS F1 FOR DEFINITION OF DENTAL CHECK-UP.
----------------------------------------------------
| IF PERSON BEING ASKED ABOUT IS 18 YEARS OF AGE OR |
| OLDER (OR IN AGE CATEGORIES 4-9), CONTINUE WITH |
| AP16 |
----------------------------------------------------
----------------------------------------------------
| IF PERSON BEING ASKED ABOUT IS 16 OR 17 YEARS OF |
| AGE, GO TO AP32 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (THAT IS, PERSON BEING ASKED ABOUT IS |
| LESS THAN 16 YEARS OF AGE OR IN AGE CATEGORIES |
| 1-3), GO TO BOX_02 |
----------------------------------------------------
AP13
====
OMITTED.
AP14
====
OMITTED.
AP15
====
OMITTED (BLOOD PRESSURE ITEM)
AP16
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how long has it been since (PERSON) had (PERSON)’s blood
cholesterol checked by a doctor or other health professional?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF BLOOD CHOLESTEROL CHECK.
[Code One]
AP17
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
A routine check-up is a visit with a doctor or other health
professional for assessing overall health, usually not prompted
by a specific illness or complaint. It usually includes a blood
pressure check, and may include taking a blood sample for
analysis and questions about health behaviors such as smoking.
About how long has it been since (PERSON) had a routine
check-up by a doctor or other health professional?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
[Code One]
AP18
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how long has it been since (PERSON) had a flu shot?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF FLU SHOT.
[Code One]
AP18A
=====
OMITTED (DENTURE ITEM)
AP18B
=====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) lost all of (PERSON)’s upper and lower
natural (permanent) teeth?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
BOX_01A
=======
----------------------------------------------------
| IF PERSON BEING ASKED ABOUT IS MALE AND IS 40 |
| YEARS OF AGE OR OLDER (OR IN AGE CATEGORIES 6-9), |
| CONTINUE WITH AP19 |
----------------------------------------------------
----------------------------------------------------
| IF PERSON BEING ASKED ABOUT IS MALE AND IS LESS |
| THAN 40 YEARS OF AGE (OR IN AGE CATEGORIES 4-5), |
| GO TO AP23 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (I.E., PERSON BEING ASKED ABOUT IS |
| FEMALE), GO TO AP20A |
----------------------------------------------------
AP19
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
A "P-S-A" or prostate specific antigen is a blood test for
prostate cancer. About how long has it been since (PERSON) had a
"P-S-A"?
WITHIN PAST YEAR ....................... 1 {AP23}
WITHIN PAST 2 YEARS .................... 2 {AP23}
WITHIN PAST 3 YEARS .................... 3 {AP23}
WITHIN PAST 5 YEARS .................... 4 {AP23}
MORE THAN 5 YEARS ...................... 5 {AP23}
NEVER .................................. 6 {AP23}
REF ................................... -7 {AP23}
DK .................................... -8 {AP23}
[Code One]
AP20A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) had a hysterectomy?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF HYSTERECTOMY.
AP20
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how long has it been since (PERSON) had a pap smear test?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF PAP SMEAR TEST.
[Code One]
AP21
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
During a breast exam a doctor or other health professional feels
the breast for lumps. About how long has it been since (PERSON)
had a breast exam?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
[Code One]
----------------------------------------------------
| IF PERSON BEING ASKED ABOUT IS 30 YEARS OF AGE OR |
| OLDER (OR IN AGE CATEGORIES 5-9), CONTINUE WITH |
| AP22 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO AP23 |
----------------------------------------------------
AP22
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
A mammogram is an x-ray taken only of the breast by a machine
that presses the breast against a plate. About how long has it
been since (PERSON) had a mammogram?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
NEVER .................................. 6
REF ................................... -7
DK .................................... -8
[Code One]
AP23
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
A blood stool test is a test that you do at home using a special
kit or cards provided by a doctor or other health professional
to determine whether the stool contains blood. (Have/Has)
(PERSON) ever had this test using a home kit?
YES .................................... 1
NO ..................................... 2 {AP25}
REF ................................... -7 {AP25}
DK .................................... -8 {AP25}
AP24
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
When did (PERSON) have (PERSON)'s last blood stool test using a
home kit?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
REF ................................... -7
DK .................................... -8
[Code One]
AP25
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
A sigmoidoscopy or colonoscopy is when a tube is inserted in the
rectum to view the bowel for signs of cancer or other health
problems. (Have/Has) (PERSON) ever had this exam?
YES .................................... 1
NO ..................................... 2 {AP28}
REF ................................... -7 {AP28}
DK .................................... -8 {AP28}
AP26
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
When did (PERSON) have (PERSON)'s last sigmoidoscopy or
colonoscopy?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3
WITHIN PAST 5 YEARS .................... 4
MORE THAN 5 YEARS ...................... 5
REF ................................... -7
DK .................................... -8
[Code One]
AP27
====
MOVED TO END OF SECTION (SEATBELT ITEM)
AP28
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Do/Does) (PERSON) now spend half an hour or more in moderate
or vigorous physical activity at least three times a week?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF MODERATE OR VIGOROUS PHYSICAL ACTIVITY.
AP29
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how tall (are/is) (PERSON) without shoes?
PROBE FOR INCHES IF NOT REPORTED.
AP29_01
=======
ENTER FEET:
[Enter Feet] ...........................
REF ................................... -7 {AP30}
DK .................................... -8 {AP30}
----------------------------------------------------
| SOFT RANGE CHECK: 2 TO 6 |
----------------------------------------------------
AP29_02
=======
ENTER INCHES:
[Enter Inches] .........................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| SOFT RANGE CHECK: 0 TO 12 |
----------------------------------------------------
AP30
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how much (do/does) (PERSON) weigh without shoes?
ENTER CURRENT WEIGHT TO THE NEAREST POUND.
[Enter Pounds] ......................... {AP32}
REF ................................... -7 {AP32}
DK .................................... -8
----------------------------------------------------
| SOFT RANGE CHECK: 50 TO 500 |
----------------------------------------------------
AP31
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
SHOW CARD AP-1.
Looking at this card, what is your best guess of (PERSON)'s
weight?
79 POUNDS OR LESS ...................... 1
80 TO 99 POUNDS ........................ 2
100 TO 119 POUNDS ...................... 3
120 TO 139 POUNDS ...................... 4
140 TO 159 POUNDS ...................... 5
160 TO 179 POUNDS ...................... 6
180 TO 199 POUNDS ...................... 7
200 TO 219 POUNDS ...................... 8
220 TO 239 POUNDS ...................... 9
240 TO 259 POUNDS ...................... 10
260 TO 279 POUNDS ...................... 11
280 TO 299 POUNDS ...................... 12
300 TO 319 POUNDS ...................... 13
320 TO 339 POUNDS ...................... 14
340 TO 359 POUNDS ...................... 15
360 TO 379 POUNDS ...................... 16
380 TO 399 POUNDS ...................... 17
400 POUNDS OR MORE ..................... 18
REF .................................... -7
DK ..................................... -8
[Code One]
AP32
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
When (PERSON) drive(s) or ride(s) in a car, would (PERSON) say
(PERSON) wear(s) a seat belt...
IF RESPONDENT VOLUNTEERS THAT PERSON NEVER DRIVES OR RIDES IN
A CAR (E.G., ALWAYS USES PUBLIC TRANSPORTATION, WALKS, ETC.),
CODE '6'.
Always, ................................ 1
Nearly Always, ......................... 2
Sometimes, ............................. 3
Seldom, or ............................. 4
Never? ................................. 5
NEVER DRIVES/RIDES IN A CAR ............ 6
REF ................................... -7
DK .................................... -8
[Code One]
BOX_02
======
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| GO TO NEXT QUESTIONNAIRE SECTION. |
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