US. DEPARTMENT OF HEALTH AND HUMAN SERVICES - Public Health Service - Office of Health Research, Statistics, and Technology - National Center for Health StatlSthS' Series 1, No. 15 _A. “a... _‘. A- Plan and Operation of the Second National Health and Nutrition Examination Survey 1976-80 Programs and Collection Procedures Series 1, No. 15 Library of Congress Cataloging in Publication Data United States. National Center for Health Statistics. Plan and operation of the second National Health and Nutrition Examination Survey, 1976-1980. (Vital and health statistics: Series 1, Programs and collection procedures; no. 15) (DHHS publication; no. (PHS) 81-1317) Prepared by A. McDowell and others. Includes bibliographical references. Supt. of Docs. no.: HE 20.6209:1/15 1. Health and Nutrition Examination Survey. I. McDowell, Arthur. ll. Title. III. Series: United States. National Center for Health Statistics. Vital and health statistics: Programs and collection procedures; no. 15. W. Series: United States. Dept. of Health and Human Services. DHHS publication; no. (PHS) 81-1317. [DNLM: 1. Health surveys—United States. 2. Nutrition surveys—United States. W2AN148va no. 15] RA409.U44 no. 15 [RA407.3] 312 ’ . 0723s 80-607914 ISBN 0-8406-0193-X [312 ' . 0723] For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, DC. 20402 Plan and Operation of the Second National Health and Nutrition Examination Survey 1976-80 Programs and Collection Procedures Series 1, No. 15 A description of the National Health and Nutrition Examination Survey of a probability sample of the US. population 6 months through 74 years of age. PUBLIC HEALTH Liamv MAR 26 1985 UNIVERSITY OF CALiF. BERKELEY DHHS Publication No. (PHS) 81-1317 US. Department of Health and Human Services Public Health Service Office of Health Research, Statistics, and Technology National Center for Health Statistics Hyattsville, Md. July 1981 Vllfll [Mill WISHES National Center for Health Statistics DOROTHY P. RICE, Director ROBERT A. ISRAEL, Deputy Director JACOB J. FELDMAN, Ph.D., Associate Director for Analysis and Epidemiology GAIL F. FISHER, Ph.D., Associate Director for the Cooperative Health Statistics System GARRIE J. LOSEE, Associate Director for Data Processing and Services ALVAN O. ZARATE, Ph.D., Assistant Director for International Statistics E. EARL BRYANT, Associate Director for Interview and Examination Statistics ROBERT C. HUBER, Associate Director for Management MONROE G. SIRKEN, Ph.D., Associate Director for Research and Methodology PETER L. HURLEY, Associate Director for Vital and Health Care Statistics ALICE HAYWOOD, Information Officer Division of Health Examination Statistics ROBERT S. MURPHY, Director JEAN ROBERTS, Chief, Medical Statistics Branch SIDNEY ABRAHAM, Chief, Nutritional Statistics Branch KURT R. MAURER, Chief Survey Planning and Development Branch Division of Data Services PHILLIP R. BEATTIE, Director HENRY W. MILLER, Chief, Health Examination Field Operations Branch Office of Research and Methodology JAMES T. MASSEY, Ph.D., Chief: Survey Design Staff Under the legislation establishing the National Health Survey, the Public Health Service is authorized to use, insofar as possible, the services or facilities of other Federal, State, or private agencies. In accordance with specifications established by the National Center for Health Statistics, the U.S. Bureau of the Census participated in the design and selection of the sample and carried out the household interview stage of the data collection and certain parts of the statistical processing. The Center for Disease Control acted as laboratory consultants and performed a series of biochemical, hematological, and serological assessments on blood specimens of persons participating in the survey. Library of Congress Catalog Card Number 80-607914 Contents Introduction ............................................................................ Planning process ......................................................................... Summary statement of data collection techniques ................................................... Questionnaires ........................................................................ Examination by physician ................................................................. Special clinical procedures and tests .......................................................... X-rays .............................................................................. Urine tests ........................................................................... Tests on blood samples ................................................................... Nutritional status assessments ................................................................ Detailed health examination ................................................................. Major new target conditions ............................................................... Other important target conditions ........................................................... Sample design for NHANES || ................................................................ Design specifications .................................................................... Definition and stratification of primary sampling units .............................................. Formation of superstrata in NHANES ll ....................................................... Selection of sample locations ............................................................... Selection of housing units within sample locations ................................................. Selection of sample persons ................................................................ Operational plan ......................................................................... Stand sequencing and scheduling ................................. A ........................... Advance contacts and logistics .............................................................. Household interviewing and appointment process ................................................. Examination center and staff ............................................................... Examination process and medical reports ....................................................... Quality control .......................................................................... Pilot testing ............................................................................ Plans for analysis and publication of data ......................................................... References ............................................................................. ND menu-bags: 33 34 35 Appendixes Contents .............................................................................. I. Examination components by age groups .................................................... ll. Blood and urine assessments by specimen types and age groups ..................................... Ill. Pesticide residue and metabolite determinations ............................................... IV. National Center for Health Statistics and Center for Disease Control staff involved in the planning, development, and operation of NHANES || .............................................................. V. Data collection forms for NHANES || ...................................................... List of Text Figures 1. 2. 3. Comparison of regional boundaries for the National Health and Nutrition Examination Survey, 1976-80, with those defined by the U.S. Bureau of the Census ....................................................... An example of a sample person selection sheet used in the National Health and Nutrition Examination Survey, 1976-80 . . Mobile examination center ................................................................ List of Text Tables I'HUOW > 'I'I . Number and population of National Health Interview Survey (NHIS) strata before and after subdivision of self-representing primary sampling units, by type of stratum and National Health and Nutrition Examination Survey region ........... . Variables in final stepwise regression model, by region .............................................. . Correlation matrix for health and sociodemographic variables ......................................... . Variables used for stratification in the National Health and Nutrition Examination Survey, by region ............... . Definition of control classes used for the selection of primary sampling units, by region: National Health and Nutrition Examination Survey, 1976-80 .............................................................. . Expected and actual number of sample primary sampling units (PSU’s) within control classes, by region and type of stratum ............................................................................. . Primary sampling units, stand sites, and percent of persons examined, by region: National Health and Nutrition Examina- tion Survey, 1976-80 .................................................................... Symbols - - « Data not available Category not applicable Quantity zero 0.0 Quantity more than zero but less than 0.05 Z Quantity more than zero but less than 500 Figure does not meet standards of reliability or precision # Figure suppressed to comply with confidentiality requirements 37 38 39 40 41 43 18 28 17 20 21 22 23 24 25 Plan and Operation of the Second National Health and Nutrition Examination Survey. 1976-80 by Arthur McDowell, formerly with Division of Health Examination Statistics, Arnold Engel, M.D., Division of Health Examination Statistics, James T. Massey, Ph.D., Office of Research and Methodology, and Kurt Maurer, Division of Health Examination Statistics Introduction The second National Health and Nutrition Exam- ination Survey is another in a series of related pro- grams carried out over the past 20 years by the National Center for Health Statistics. These programs, authorized by Congress under the National Health Survey Act of 1956, are characteristically national in scope, based on probability sampling, and used to collect a broad range of morbidity data and related health information. The essential differentiating characteristic of the health examination surveys is their primary concern with those kinds of health- related data obtained only (or at least optimally) from specially standardized direct medical examina- tions, including tests and other procedures used in clinical practice. Such examinations given to persons selected in the scientific sample permit estimates of the prevalence of specifically defined diseases in the US. population, including cases not previously identified. They also permit estimation of the distri- bution within the population of a broad variety of health-related measurements, including not only physical measurements such as height, weight, and various skinfolds, but also physiological measure- ments, such as diastolic blood pressure and serum cholesterol level and psychological measurements. During the years 1959-76, the National Center for Health Statistics (NCHS) conducted four separate examination surveys. The first of these, the National Health Examination Survey, Cycle I, (NHES I) focused on the prevalence of selected chronic disease in civilian noninstitutionalized US. adults aged 18-79.1 The next two surveys, which were conducted from July 1963 through March 1970, were largely devoted to the growth and development of children 6-11 (the National Health Examination Survey, Cycle II—NHES II)2 and 12-17 years of age (the National Health Examination Survey, Cycle III—NHES III).3 The fourth survey introduced a new emphasis. In 1969 the Department of Health, Education, and Welfare established within NCHS a continuing activity to measure the nutritional status of the US. popula- tion and to monitor changes in status over time. After careful study by an NCHS task force, it was decided to combine the proposed national nutrition surveil- lance survey with the existing National Health Exam- ination Survey in order to enhance the performance of each component and to permit relating nutritional variables to health measures. The resultant survey is known as the National Health and Nutrition Exam- ination Survey, or NHANES. The first segment of NHANES (the National Health and Nutrition Examination SurveyfiNHANES I) was conducted from 1971 through 1974.4 An assessment of nutritional status was made on a representative sample of the US. population aged 1-74 years, and a detailed examination was given to a subsample aged 25-74 years. This segment of the NHANES I program was followed by a 14—month period (1974—75) in which an additional national sample of persons 25-74 years of age was given the detailed examination, to augment the size of the sample originally included in NHANES I (referred to as the National Health and Nutrition Examination Survey, Augmentation Cycle— NHANES IA).5 Data collected in successive surveys have been published in more than 100 separate publications6 and have also been made available on computer tapes for further study.7 The reports serve a broad spectrum of uses: 0 They provide estimates of the prevalence of char- acteristics or conditions. 0 Normative or descriptive data permit the monitor- ing or measurement of changes in health and nu- tritional status over time through successive assessment surveys. 0 Problems of possible public health importance can be identified. 0 The interrelationship of health and nutritional variables in the general population is made possible. Planning process The continuing responsibility for measuring and monitoring the nutritional health status of the US. population meant that the first assessment survey, NHANES I, would be followed by later assessment surveys. These would permit comparisons with the NHANES I baseline data and thereby allow measure- ments of changes over time. Thus, in a sense, the planning of the nutritional aspects of the second National Health and Nutrition Examination Survey, 1976-80, NHANES II, began with NHANES 1. Throughout the course of its operation there was an awareness of this. Constant consideration was given to procedures and content items in terms of whether they should be repeated in the succeeding survey. Then, too, the necessity for comparing NHANES II data with those from NHANES I re- quired that some of the same measurements be made in the same way and on the same age segment of the US. population in both surveys. The complex process of planning the NHANES II program began in a systematic way, however, only in mid-1974, about a year and a half before the survey was to begin opera- tion. The planning phase of a national health examina- tion survey 'is critically important. The planning process used in the NHANES and predecessor surveys has been described in more detail elsewhere, but part of that statement deserves repeating here: One aspect of planning is of prime impor- tance, namely, specifying the survey’s specific goals or substantive purposes. . . With respect to each element to be considered for inclusion in a health examination survey—for example, information on diabetes—the following ques- tions should be answered by the appropriate personnel: (i) How and for what purposes will the infor- mation be used? (Outlines of proposed analyses are desirable.) (ii) What specific data are needed? (iii) How can those data be obtained? (What specific tests, measures, and questionnaire items are needed, and what level of skill is required of examining personnel?) (iv) Is the health examination survey the appro- priate mechanism to get these data? (v) Is the expected prevalence level consonant with the ability of the planned survey to determine it within reasonable confidence limits? (vi) Can the entire process of obtaining these data be adequately standardized? (vii) What cost factors are involved in equip- ment, laboratory work, skilled personnel, and so on? _ (viii) Finally, if questions (i)-(vii) all are answered satisfactorily—What is the place of this par- ticular data need in an ordered priority listing with other potential needs? The appropriate personnel vary with the question asked. For example, for question (i), the head of a health planning agency would qualify, while for (iii) it might be an expert in the medical specialty involved. In the USA the process of determining the conditions to be included in each health examination survey has been a multi-stage effort involving hundreds of institutions, organi- zations, and individuals. At the beginning a wide net is cast and opinions are sought from hundreds of health planners, health researchers, medical care providers, and health educators as to the kinds of data, appropriate to this type of survey, that are mest needed. Important in this stage is the input from Federal Government agencies, particularly the various elements of the Depart-. ment‘ of Health, Education, and Welfare. Further follow-up contacts are made with respect to some of the suggested items which seem to be reason- able prospects for inclusion, and information is obtained in greater detail so as to answer each of the questions listed in the preceding paragraph. This leads to further stages of consultation and perhaps to convening ad hoc meetings of experts in a particular field to assist in determining feasibility and relative priorities. In the end, decisions must be made at the level of the NCHS, but these must be approved at successive Govem- mental levels up to the Office of Statistical Policy within the Office of Management and Budget in the Executive Office of the President.8 The processes described in the foregoing para- graphs were the general pattern of the planning process carried out in 1974 and 1975 to determine the content and data goals of the NHANES II pro- gram. During this same time many related determina- tions had to be made concerning sample size and design, method of operation in data collection, quality control procedures, field staff retraining, pilot testing and pretesting, and further resultant modifica- tions. Although it has not been unusual for NCHS to collaborate with other Federal agencies in the plan- ning, data collection, and analysis of previous Na- tional Health Examination Surveys, the level of col- laboration involved in NHANES II was unprece- dented: 0 The Bureau of Laboratories, Center for Disease Control, served as a technical consultant for the planning and quality control of NHANES labora— tory efforts, in addition to performing most of the health— and nutrition-related biochemistry and providing some of the funding for this effort. 0 The National Institute of Arthritis, Metabolism, and Digestive Diseases, National Institutes of Health, supported the serum creatinine testing, the development of a glucose tolerance testing protocol, plasma glucose determinations at the Center for Disease Control, and processing of the data to make it more quickly available for analysis. 0 The National Heart, Lung, and Blood Institute, National Institutes of Health, developed plans for assessing cholesterol, triglyceride, and high density lipoprotein (HDL) levels through the Lipid Research Clinic Laboratory at George Washington University, the results processed at the Coronary Patient Registry at the University of North Carolina. 0 The Office of Pesticides and Toxic Substances, Environmental Protection Agency, served as a technical consultant in collecting blood and urine specimens suitable for processing for residues and metabolites of certain pesticides. It processed the samples, monitored the quality of the processing, and coded the data in machine-readable form. 0 The Bureau of Foods, Food and Drug Administra- tion, supported the development of a serum ferritin assessment as part of the characterization of anemia. It also supported the measurement of blood lead levels at the Center for Disease Control. 0 The Department of Energy supported Dr. Edward Radford at the University of Pittsburgh in his assessment of carboxyhemoglobin levels in blood. Randomly selected blind samples both from Dr. Radford’s laboratory and from NCHS mobile examination centers were analyzed by accepted gas chromatographic procedures at the Naval Medical Research~lnstitute, insuring quality con- trol and providing a reference standard. 0 .The Bureau of State Services, Center for Disease Control, made arrangements in each sample area for supplies and testing for gonorrhea. The remaining sections of this report present the outcome of the planning with respect to the objectives of NHANES II. They describe in more detail some of the reasons for the selections and go into details of the sample design and operational plan. The appendixes of this report contain listings of the examination components; blood and urine assess- ments; pesticide residue and metabolite determina- tions;staff participation in the planning, development, and operation of NHANES II; and data collection forms. Summary statement of data collection techniques The plan developed with respect to the content of NHANES 11 called for the following items. Questionnaires Household questionnaire—For each household member, this questionnaire included the family relationships; certain demographic items such as age, sex, and race; selected housing information; items such as occupation, income, veteran status; and an indication of participation in food stamp programs. Medical history questionnaires—For each sample person at ages 6 months to 11 years a questionnaire included items on birth weight, prematurity, develop- mental congenital conditions, medication, neuro- logical conditions, lead poisoning, accidents, hospital care, disability, diarrhea, pica, vision, and a variety of chronic conditions. In addition, there were major sections on allergies, kidney and bladder disease, anemia, speech and hearing, lung and chest condi- tions, and participation in food programs. Two questionnaires for each sample person at ages 12-74 years included items on medication; hos- pital care and tuberculosis; nutrition; a variety of acute and chronic diseases; tobacco, tea, and coffee usage; physical activity; weight; height; vision disa- bility; exposure to pesticides; gastrointestinal prob- lems; and for females, a menstrual and pregnancy history. In addition, there were major sections on anemia, diabetes, respiratory condition, hearing and speech, liver and gallbladder conditions, kidney and bladder disease, allergies, hypertension, cardiovascular conditions, stroke, arthritis (stressing middle and upper back and neck problems), and participation in food programs. Two dietary questionnaires—For each sample person, a dietitian recorded the quantity of every item of food or drink consumed during the previous day, so that after computer calculation, the data yielded measures of calories, cholesterol, fat, unsaturated fats, protein, carbohydrates, and specific 4 vitamins and minerals. consumed during the recall period. A food frequency interview ascertained the usual pattern of food consumption, recording whether or not it included any foods in various groupings, in- cluding milk, meat, fish, eggs, fats and oils, legumes and nuts, cereals, fruits, vegetables, and alcoholic beverages. It also showed reported daily and/or weekly number of times each food was consumed and noted the use of salt and vitamin and mineral sup- plements. Medications and vitamin usage—This elicited a history of the preceding week’s usage of any medicines, vitamins, or minerals, for all examined persons. Dietary supplement interview f0rm.—,This form recorded the history of special diets, prior medications, and barriers to purchasing groceries or eating foods for examined persons aged 12-74 years. Behavior questionnaire—This questionnaire elicited data on behavior possibly associated with coronary heart disease for examined persons 25-74 years of age. Examination by physician A physician performed and. recorded a medical examination giving special attention to specified findings related to nutrition; hearing; the thyroid gland; and the cardiovascular, respiratory, neurolog- ical, and musculoskeletal systems. Special clinical procedures and tests A specially trained health technician carried out the following tests and procedures on examined persons in the designated age ranges. Spirometry trials—These were. digitized and recorded on magnetic tape for examined persons 6-24 years of age for various pulmonary function indicators such as forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), and peak flow rate. Electrocardiograms.—Digitized and recorded on magnetic tape for examined persons 25-74 years of age, electrocardiograms provided normative data on amplitudes and durations and permitted diagnostic interpretations of heart disease according to the Minnesota code. Body measurements—The measurements made on examinees included standing height, body weight, triceps and subscapular skinfolds, and several others. Puretone audiometry.—This test carried out on examined persons between the ages of 4 and 19 permitted determination of threshold levels of hearing for frequencies of 500, 1000, 2000, and 4000 Hertz for right and left ears. Speech recording—This involved the use of a tape recording of the subject’s repetition of specially de- veloped sentences. It was carried out on examined persons between the ages of 4 and 6, permitting in- terpretations as an indication of problems with articu- lation and language development. Allergy tests—These involved skin tests (the prick test) with eight common allergens (housedust, alter- naria, cat fur, dog fur, ragweed, oak, rye grass, and Bermuda grass). The tests were made on examined persons between the ages of 6 and 74 to obtain de- grees of skin reaction. X-rays For examined persons 25-74 years of age two X-rays were made. No X—rays were done on pregnant women, and no lumbar X-rays were done on women under 50 years of age. X-ray of cervical and lumbar spine—This provided evidence of osteoarthritis and degenerative disc disease. X-ray of chest.—The chest X-ray was used in the diagnosis of respiratory diseases and served as a measure of left ventricular enlargement. Urine tests Tests as follows were performed on casual sam- ples of urine. N—Multistix tests—These urinary dipstick tests for qualitative protein, glucose, ketones, bilirubin, blood, urobilinogen, pH, and bacteriuria (nitrite test) were done for examined persons 6-74 years of age. Urinary sediments—Sediments including red cells, white cells, and casts were measured for a subsample of examined adults 20-74 years of age. Gonorrhea cultures—Cultures of urinary sediments were performed for male and female examined persons 12-40 years of age. However, of those females who received the glucose tolerance test (GTT), only those 20-24 years of age had the gonorrhea test performed. Analyses for pesticide levels—Urine samples from a subsample of examined persons 12-74 years of age were tested for the presence of alkyl phosphate resi- dues and metabolites, carbamate residues, phenolic compound residues and malathion metabolites. Appendix III has a complete listing of the pesticide residues and metabolites tested for. Tests on blood samples Samples of blood provided a broad range of information related to health and nutrition. The particular tests performed varied with the specific target condition and age group (appendix II). The discussion of the development of the plan for NHANES II later in this report specifies the age groups and, in some instances, the subsampling pattern followed for each of the following tests. Glucose tolerance test.—This test involved the collection of blood specimens from examined persons while they were in a fasting state as well as at 1 and 2 hours after glucose challenge. The test was performed on a specified subsample of examined adults to provide estimates of the prevalence of diabetes. Tests related to liver function—The postprandial liver bile acid test measured the ability of the liver to remove bile acids from the blood following consump- tion of a food preparation that induced the eventual addition of bile acids to the blood via contraction of the gallbladder. Biochemical liver tests performed included bili- rubin, SGOT, and alkaline phosphatase. Anemia-related laboratory tests—The tests made to diagnose anemia consisted of protoporphyn'n, iron, total iron binding capacity (TIBC), zinc, copper, red cell folates, serum folates, serum ferritin, vitamin B12, and the determination of abnormal hemoglobin. Other biochemical nutritional tests—These tests included albumin, vitamin A, and vitamin C. Serum lipidsrBecause of their important relevance to cardiovascular disease, determinations were made of cholesterol, triglycerides, and high density lipoprotein (HDL). Biochemical tests for body burden from environ- mental exposures—Determinations were made of the levels of lead and organochlorine pesticide residues and metabolites. Tests were also performed for carboxyhemoglobin, which reflects environmental exposure to carbon monoxide and the individual’s smoking habits. Hematology—The hematology included determi- nations of hemoglobin, hematocrit, red blood cell count, white blood cell count and differential analysis, and red blood cell morphology. Kidney function—The only test for kidney function performed on blood samples was the serum creatinine test. Syphilis—The serology determinations for syphilis included qualitative and quantitative ART, an FTA—ABS, and MHA—TP. The foregoing list summarizes the content finally decided upon for inclusion in NHANES II. However, the planning process almost always involves a great deal of effort in connection with proposals that, for a variety of reasons, are not included in the final plan. A few of the important components considered in the process of planning but deleted from the final NHANES 11 plan deserve to be noted. Two of the proposals that Were seriously considered had to be deleted because of staff limitations or examination time. One of these would have involved administering a tuberculin skin test at the examination site with subsequent reading at the household; the other would have involved administration of a psychological schedule used in NHANES I, the General Well-Being Test. A third proposal involved completion of a questionnaire at the school attended by children and youth who were sample persons. In that case, con- siderations related to confidentiality and privacy, and the related clearance process required more time than was available for their resolution. Finally, in the early stages of planning, consideration was given to includ- ing an extensive neurological component based on computer analysis of tape recorded electroencephalo- grams. The main purpose would have been the provision of normative data on the distributions of the electroencephalogram variables in the general population and of some data on the prevalence of brain damage and related brain pathology. It was finally decided to drop this from NHANES II, with the, possibility of considering it in a later program. A major factor in this decision was the recommendation by the National Institutes of Health advisory com- mittee that reviewed the plan. While approving the general concept of such data collection and analysis, this group believed that the methodology available at the time was not appropriate for use in NHANES 11. Certain other components considered in planning but finally omitted from NHANES II are nofted later in the detailed description in this report. Nutritional status assessments The basic purpose of the NHANES 11 program yvith respect to nutritional status assessment required that the program continue to use, with some modifi- cation, the same or essentially the same format of NHANES I. In order to monitor the nutritional status of the population, the data to be collected needed to be not only comparable, at least in considerable part, but also carried out as in NHANES I on a probability sample of the civilian noninstitutionalized population of the United States. Again asinNHANES I, emphasis needed to be placed on the segments of the popula- tion classified as at or below the poverty level, the young children and the aged, since these were as- sumed to be at special risk of having nutritional problems. These groups then would again be sampled at rates substantially higher than their proportions in the general population. It is necessary, in order to assess nutritional status, to obtain data of four different types. The fourfold approach used in NHANES I and NHANES II involved the collection of information on dietary intake patterns along with the results of various hematological and biochemical tests, anthropometric measurements, and clinical assessments. The experience gained in the NHANES I program, however, made possible certain modifications of NHANES II in order to make the data obtained more useful while continuing to provide a considerable amount of comparable data for monitoring purposes. The NHANES I information indicated that vitamin A deficiencies were not a problem in the older age groups in our US. population, and as a result, col- lection of information on the biochemical findings of vitamin A was limited in NHANES II to the 3-11 years age group. (It was not recognized at the time that vitamin A levels in adults would be of considerable interest in cancer research.) Technical problems in the collection of blood samples and their analysis for vitamin C during the NHANES I program had re- sulted in unsatisfactory data. These problems were solved, and vitamin C determinations were again made in NHANES II. The methods used in NHANES I for determining the iodine, thiamine, and riboflavin values in urine were found to be inadequate, how- ever. Therefore, the decision was made to exclude those determinations from NHANES II. Some con- sideration was given to using the more sensitive enzyme analysis method to detect any riboflavin or thiamine deficiencies. Some of the investigations at the Center for Disease Control involved the spectro— photometric erythrocyte transketolase method as well as a spectrophotometric method for erythrocyte gluthathione reductase. This work identified a num- ber of compromises in basic enzyme assay princi- ples and certain questions in the color development procedure that would require a considerable amount of additional time to evaluate fully. It was, therefore, decided not to include these in the NHANES II program. On the other hand, the serum albumin test used in NHANES I was continued in NHANES II as a monitor of protein deficiency in the US. population. The relationship of the serum albumin test to clinical health status was also an important factor in its retention, since as a whole there is little evidence of a gross pattern of protein deficiency in the US. popula- tion. An important addition in NHANES II to the bio- chemical data obtained in NHANES I related to the investigation of the trace elements zinc and copper in blood. It was known in 1974 that there are more than 70 enzymes that need zinc for their proper function. Important factors in decreasing the absorption of dietary zinc are the fiber and phosphates in predom- inantly cereal-based diets. The consumption of alcohol increases urinary excretion. A number of diseases such as steatorrhea, regional enteritis, liver cirrhosis, hemolytic anemia, psoriasis, thalassanemia, and sickle cell disease may lead to zinc deficiency. Pregnancy may also predispose to zinc deficiency. Zinc is involved in the production of insulin, and zinc deficiency may impair wound healing. Copper defi- ciency is important for a number of reasons. The first 7 sign of copper deficiency in humans is usually neutro- penia. In advanced copper deficiency, iron is not absorbed. A copper-containing enzyme (cerulo- plasmin) is necessary for the human body to use iron. Copper is essential in hematopoiesis and plays a key role in connective tissue metabolism. Since in trace element surveys many factors can grossly interfere with the integrity of the specimens, a number of precautions were taken. A thorough investigation was made of various aspects of the collection, storage, stability, and possibilities of contamination of specimens. Special blood-drawing equipment and specimen storage containers were employed. A laminar flow table was used to prevent airbom contamination during specimen processing at the laboratory in the examination center. As in the NHANES I program, the two principal means of obtaining data on dietary intake were the 24—hour recall and the food frequency questionnaire. In order to facilitate comparison of the various types of information, the schedules used were modified somewhat in NHANES 11 so that both of them used identical food groupings. This was done in a way that still permits the comparison of NHANES II with NHANES I data. Considerably increased amounts of information on vitamin and mineral supplements were obtained in NHANES II as compared with NHANES I. In NHANES 11, information was obtained on participa- tion in such food programs as food stamps, commodi- ties, school lunches, home-delivery meals, and the like. This information will permit comparisons between the measures of nutritional status of individuals par- ticipating in these programs and individuals of similar socioeconomic status who are not participating. The body measurements obtained in NHANES II, the third part of the fourfold approach to assessing nutritional status, were the same as those used in NHANES I. They were as follows: standing height, sitting height, weight, bitrochanteric breadth, elbow breadth, upper arm girth, head circumference, triceps skinfold, and subscapular skinfold. The only change made was to obtain measures in 3-year-olds of both standing height and recumbent length, along with sitting height and a crown-rump measurement. The fourth approach to assessing nutritional status, a physician’s examination, was also largely unchanged from the examination given in NHANES I. The examining physician’s clinical diagnostic impres- sion was based on the physical examination and medical history along with the examining physician’s own reading of the electrocardiogram and X—ray and the results of some laboratory determinations imme- diately available at examination time (hematocrit, hemoglobin, white blood cell, red blood cell, red- blood-cell—urinary test tape, and microscopic urinal- ysis). The examining physician’s reading of the electrocardiogram and X-ray were not, of course, equivalent to the readings that were obtained later from medical specialists. The examining physician’s clinical diagnostic impression of many conditions was, in fact, based on much less than a complete workup. For many other conditions, however, the examining physician’s clinical diagnostic impression may have had a reasonable degree of accuracy. For their diagnostic impressions, the physicians entered the four—digit coding of the Eighth Revision Interna- tional Classification of Diseases, Adapted for Use in the United States9 rather than the three-digit code used in NHANES I. The most important change in the approach to nutritional assessment adopted for the NHANES II program was in relation to anemia. Since this condi- tion had been revealed by NHANES I to be a signifi- cant health problem in the US population, anemia was investigated in more detail in NHANES II. The approach used to characterize anemia was one that had been recommended by Dr. William Darby, Presi- dent of the Nutritional Foundation, Inc., Center for Disease Control personnel, and others. It involved symptoms, signs, and causes of anemia gathered in medical history questionnaires and physicians’ exam- inations; and it involved laboratory assessments in blood as follows: 0 A complete blood count: hematocrit, hemoglobin, white blood cell, red blood cell, dell differential, red cell morphology, and the determination of hemoglobinopathies. 0 Iron, iron—binding capacity, serum ferritin, and red cell protoporphyrin to designate iron status. 0 Serum folates, red cell folates, vitamin B12, zinc, copper, lead, and other indicators of anemia. The folate, ferritin, and vitamin B12 determina- tions were done on anemic individuals and on a sub- sample of the entire group. This approach used to characterize anemia should make a better determina- tion of the prevalence of anemia in the US. popula- tion possible than could be done from the NHANES I data and will enable the relationships among the va- rious iron—related measures to be characterized. Such a determination is important for various public policy actions such as recommendations for enrichment of food products with iron. Detailed health examination Major new target conditions The NHANES programs have been referred to as dual-purpose surveys, the purposes involving the assessment of both nutritional and health status. It might be more precise to refer to them as surveys to measure health status with special emphasis on one of the major determinants of health—nutrition. Be that as it may, information about a number of health conditions regarded as target conditions was collected in NHANES I, and many of these same target condi- tions were included in NHANES II. The new tar- get conditions included in NHANES II were diabetes, kidney pathology, liver function, and allergy. ’ Diabetes.—Diabetes has long been recognized as an extremely serious disease affecting a significant proportion of the U.S. population. Despite this fact, there has been wide variation in the estimated prevalence of diabetes in the population. A problem arises as a result of the presence of unrecognized or undiagnosed cases of diabetes that need to be added to the recognized or diagnosed to obtain the total prevalence. A health examination survey is an ideal mechanism to obtain prevalence estimates that include both diagnosed and undiagnosed cases. The prevalence of known cases of diabetes has been moni- tored by another NCHS survey, the National Health Interview Survey, and unpublished data from that program appears to indicate an increase in the pre- valence of diabetes. The apparent increase, however, may be due oto the wider use of diabetes-detecting clinical tests in the U.S. population and not to a true increase in the prevalence of the disease. The first National Health Examination Survey (1960-62) provided some information on the prevalence of diabetes, based on a l-hour glucose tolerance test, 10-13 but a closer approximation to a standard glucose tolerance test than was then used14 would have been essential to provide an adequate estimate of the total prevalence of diabetes mellitus. Increased attention to diabetes was mandated by the National Diabetes Mellitus Research and Education Act, enacted by Congress on July 23, 1974 (Public Law 93-354). Its purpose was to (l) expand the authority of the National Institutes of Health to advance the na- tional attack on diabetes mellitus; and (2) as part of that attack, to establish a long- range plan to (A) expand and coordinate the national research effort against diabetes mel- litus; (B) advance activities of patient educa- tion, professional education, and public education which will alert the citizens of the United States to the early indications of diabetes mellitus; and (C) to emphasize the significance of early detection, proper control and complications which may evolve from the disease. In planning NHANES II, NCHS worked closely with the National Commission on Diabetes (estab— lished under Public Law 93-354) and with the Na- tional Institute of Arthritis, Metabolism, and Digestive Diseases of the National Institutes of Health. Dr. G. Donald Whedon, Director of this Institute, specially requested that a diabetes component be included in NHANES II in order to determine both the preva- lence of diabetes mellitus in the U.S. population and the ratio of previously diagnosed to undiagnosed cases. In addition, the distribution of diabetes within the population according to various demographic characteristics was of interest. In addition to the assistance obtained from the National Institutes of Health directly, a number of consultants on the diabetes component were used in planning the NHANES II program. The principal ones were Drs. Peter Bennett, John O’Sullivan, Kelly West, and Harvey Knolls. A number of questions arose during the detailed 9 planning of the diabetes component. One of these was whether or not to require the consumption of a specific number of grams of carbohydrates during the 3 days before the examination. The major drawback of such a procedure for NHANES was the elimination of the 24—hour recall diet history from the nutritional dietary survey for individuals undergoing the glucose tolerance test, since the diet preparation would have seriously altered the previous day’s food intake. Con- sideration was given to interviewing persons to receive the glucose tolerance test at home at a time other than the 3 days before the examination, but limita- tions of budget and personnel precluded this solution. The question of diet preparation was brought up at a session of the work group on epidemiology of the Committee on Scope and Impact, a subcommittee of the National Commission on Diabetes. The work group did not reach general agreement. The group’s final decision was that the consump- tion of a specific amount of carbohydrates prior to the test would not be required. But data from the 24whour recall and the presence of ketones found in the urine sample would serve as an indication of whether or not there had been an inadequate con- sumption of carbohydrates prior to the test. Some consideration was also given to the conection of data reflecting levels of circulating insan and glucagon. After due consideration, it was decided to omit determinations of insulin and glucagon, largely because of the lack of adequate resources. The test finally decided upon for the diabetes component was as follows: a one-half sample of persons 20-74 years of age was scheduled for exami- nation in the mornings. (Analysis of Cycle I glucose tolerance data indicated that sample variances for this reduced sample would be low enough to permit data analysis.) Three blood glucose specimens were col- lected, a fasting one and specimens collected at 1- and 2-hour intervals after the glucose “challenge” had been drunk. Data could then be tabulated for each blood specimen, and some combination of the three values could be used to decide whether or not sample persons had diabetes. Previous studies had indicated that a 3-hour value did not contribute significantly to the diagnosis of diabetes and that attempting to obtain it would only increase nonresponse and unduly lengthen the examination time. A 75-gram glucose challenge was selected. Available information suggested that data derived from larger loading doses were generally interchangeable with the 75-gram dose. The tests were done only in the morning because glucose tolerance decreases later in the day. In general, health conditions, such as pregnancy, that were knOWn to alter carbohydrate metabolism were not grounds for exclusion from testing. The test was also given to those individuals who had been told by their physicians that they were diabetic and whose condition had been controlled by diet or by oral 10 hypoglycemic medication. The test was not given to insulin-dependent diabetics. The examinees were instructed not to eat any- thing after 11:00 pm. on the evening before the test. On the morning of the examination, after a fasting venal blood specimen had been drawn and a urine specimen had been analyzed for glucose, the examinee was given 7 ounces of caffeine-free cola (Glucola) to drink, which contained an equivalent of 75 grams of glucose. Two more specimens of blood were drawn at 1- and 2-hour intervals. The blood was processed in the examination center laboratory, and the frozen plasma was shipped to the Center for Disease Control in Atlanta, Ga. There the plasma was analyzed by the hexokinase Glucose 6-Phosphate Dehydrogenase Procedure, using an automated modification of the National Glucose Reference Method developed at the Center for Disease Control. Kidney pathology.—A second major new target condition selected for inclusion in the NHANES 11 program was kidney pathology. Very little data directly bearing on this had been collected in previous NHANES or NHES programs, and numerous requests to have a kidney component in the examination survey programs had been received over the years from the National Institutes of Health, the National Kidney Foundation, and several nephrologists in the NHANES professional inquiry groups. Malfunction of the kidneys is an important health condition, made more so by the very expensive and complex nature of the therapy that is provided by the artificial kidney. In planning this component, numerous people, including Dr. George Schreiner, Georgetown University Hospital, Dr. Nancy Cummings, National Institutes of Health, and Dr. James C. Hunt, Mayo Clinic, were consulted. A number of tests and procedures were considered in addition to an ex- panded medical history questionnaire, including a variety of questions related to urinary problems. Various modalities were investigated, some of which had to be rejected because of difficulties in the field situation. For example, because it was desirable to obtain a measure of bacteriuria, an indication of possible urinary infection, modifications of quanti- tative culture techniques and direct examination of urine for bacteria by gram stain were considered. However, to avoid the likelihood of‘false positive results, it is desirable to obtain at least three sep— arate specimens in any procedure involving a bac- terial culture. Previous examination survey experi- ence had made apparent the difficult logistical problems encountered in requiring repeated visits. Given the constraints, it was finally decided to rely upon the simple nitrite test using a dipstick to test for bacteriuria. The test is highly specific but not highly sensitive. The creatinine clearance test, a widely used test Of kidney function that involves the collection of timed urine specimens and a blood specimen, was also carefully considered. The original plans were to include a 2-hour creatinine clearance test with a water load of approximately 400 cubic centimeters at the start of the test. However, one of the major sources of error involved in 2-hour collection is in- adequate emptying of the bladder. Since the amount of urine collected in this instance would be relatively small, any retained urine could cause considerable error in test results. Methods for measuring retention of urine, such as use of isotopes, were not regarded as feasible in the field survey. Pilot testing of the timed urine collection strongly suggested that a significant number of individuals did not empty their bladders adequately. As a result of all these things, it was decided not to use the 2-hour creat- inine clearance test but to rely only on a serum creatinine test, a widely used but less sensitive in- dicator. Support for the laboratory work for this biochemical determination was provided by the National Institute of Arthritis, Metabolism, and Digestive Diseases. Microscopic examination of urinary sediments was another of the procedures considered for inclu- sion in the survey. While consideration was given to an exact quantitative test of urinary sediments using an aliquot of a timed urine specimen—a highly accurate procedure according to some reports—it was decided after the recommendation of consultants to use a method more closely approximating that used in clinical laboratories. The procedure finally adopted was the one used for urinalysis in the Mayo Clinic. It consisted of centrifuging the urine specimen, de- canting the supernatent fluid, and examining the sediment for the presence of red and white blood cells and cell casts. Ten microscopic fields were examined for each specimen, using lO—power and 40—power magnification. However, if the voided urine was dilute, the counts on urinary sediments would be much lower than if the urine sample had been highly concentrated. For this reason it was decided to do the microscopic analysis only on the adult subsample of persons 20-74 years of age who were also to receive the diabetes test. This group would have had a sufficient number of hours of fluid deprivation immediately preceding the test, during the time spent sleeping, to produce sufficiently concentrated urine (specific gravity of 1.015 or greater) for the test. This particular procedure was also used in a study of kidney disease in the Scandinavian population.15 One finding from that study was an average of almost 60- percent lower frequency of pyuria in both men and women when midstream specimens were used. Therefore, a midstream collection procedure was used for women and a 2-glass procedure for men, with the sediment analysis carried out on the second specimen. Dipstick tests for bilirubin, nitrite, urobilinogen, blood glucose, and ketones were also included in the NHANES 11 program. Optical density, as read on a refractometer, was also determined to assist in inter- preting the data, since it gives some indication of the concentration of urine. In addition, an osmolarity determination, another index of the concentration of urine, was made at the central laboratory where pesti- cide determinations in urine were made. Liver disease.——There is a lack of reliable epidemi- ological data on the prevalence of liver disease in the general population. Some information on the preva- lance of hepatitis comes as a result of serological tests; and considerable evidence based on mortality data, including autopsy records, indicates that liver disease is fairly widespread. Experts, including Dr. Paul Beck, of the National Institutes of Health, and Dr. Norman Javitt, of Cornell Medical Center, were consulted. The problem was to decide on appropriate tests to use in a sample survey. Unfortunately, the most commonly used test to detect liver disease (the BSP test), one both sensitive and specific, involves the intravenous injection of a material that may not be entirely safe. For this reason it was out of the ques- tion that it be used in the NHANES 11 program. Other tests that were considered, including various enzyme tests such as the SGOT, SGPT, alkaline phosphatase, and so on, are not as sensitive as the BSP test; nor are they specific, since results can be elevated when conditions other than liver disease are present. In this situation, Dr. Javitt suggested that a test for elevated serum postprandial bile acids be used. Bile acids are removed by the liver from blood returning to the heart via the portal vein. The liver cells rapidly secrete the recirculated bile salts into cuniculi where they pass down the ductal system to enter the gallbladder. Under the influence of gastro- intestinal horrnones, the bile is discharged into the intestine. The bile acids are then absorbed by the intestine and later enter the portal vein to start the cycle again. Because a diseased liver will not remove bile acids as efficiently as a healthy liver, and bile acids will accumulate in the blood stream, a meas- urement of bile acids in the serum is relevant. A meal containing fat causes a contraction of the gallbladder and in effect results in a greater elevation of bile acids than that occurring under fasting conditions. For the NHANES 11 survey it was decided that sufficient fat to elevate bile acids could be obtained by the sample person’s drinking an eggnog preparation. Peanut butter cups were substituted for eggnog for the occasional person who was allergic to eggs and egg products. Blood was collected 2 hours after admini- stering the eggnog preparation or the substitute, and the test was given only to adults 35 years of age and over, since the cost of laboratory work was relatively high. The results of the test were to be combined with information from special medical history ques- tions related to liver disease. Since data on alcohol 11 consumption were also collected in NHANES II, there is the possibility of relating such data to the findings with respect to liver disease. Allergy.—The need for better data on the epide- miology of allergic conditions in the US population has long been known and was specifically pointed out to the National Center for Health Statistics by Dr. Sheldon C. Siegal, who at the time was president of the American Academy of Allergy. Dr. Siegal strongly recommended that an allergy component be included in the examination survey program. Data from other NCHS surveys and from other sources showed that the clinical manifestations of allergy were responsible for a large number of ambulatory care visits and widespread use of prescription and nonprescription drugs. Seasonality would be a problem in measuring the clinical manifestations of allergies in a survey with the NHANES design because of the scheduling of the examination sites. However, reactions to skin tests are closely related to the presence of various respiratOry conditions, including asthma and allergic rhinitis.16 Further consultation on the possibility of including such a component was held with Dr. Phillip S. Norman, who succeeded Dr. Siegal as president of the Academy. It was recommended that data be col- lected, including an allergy history and the results of a skin test. At Dr. Siegal’s request, Drs. John Farghan, Charles Read, and Albert Schaeffer drew up a specific format and content for the allergy examination. The recommendation of the consultants was that the prick test be used, which, along with the scratch test, is considered to be among the safest procedures used for skin testing. The test involves pricking the skin through a drop of antigen placed on the skin. Their recommendation was adopted, as was the recommendation to use eight separate aeroallergen extracts: housedust, alternaria, cat fur, dog fur, mixed long and short ragweed, oak, perennial rye grass, and Bermuda grass. In addition to the eight allergens, two controls, one containing the diluent used for the antigens and another consisting of a histamine phosphate solution, were used. The allergy skin test was administered to exam- inees 6—74 years of age. The back, frequently con- sidered the most uniform site for skin tests, was deemed impractical to use for testing because of lack of facilities for keeping examinees in a prone position for the required time. Therefore, the non- vascular area of the forearm was used. Special pre- cautions were taken for individuals with a history of allergy to ragweed and even more particularly to cats or dogs, as revealed from the allergy history questions. After the administration of the allergens, readings were taken both at 10- and 20-minute (the more commonly used standard measurement) per- iods. Both the length and width of the wheal and its flare were measured, and standard clinical recordings were made of the allergic reaction. The consultants 12 had originally recommended that lyophilized extracts of the allergen be used, but they were not commer- cially available, and standard scratch test antigens preserved in glycerin were used instead. Other important targetconditions Osteoarthritis and disc degeneration—Osteo- arthritis is one of the most common diseases in older Americans. The disease is an important cause of disability, causing limitation of activity and mobility. Osteoarthritis has two basic causes. A gene that is very common in the population produces a syndrome of hereditary osteoarthritis associated with Heberden’s Nodes. In this condition, severe disc degeneration and degeneration of the apophysial joint of the cervical spine are commonly seen. The second type of osteo- arthritis is due to mechanical wear and tear. There‘ is little doubt that individuals who are exposed to high degrees of trauma develop severe disc degeneration of the cervical and lumbar spines. In addition to chronic pain, many syndromes may be noted. For example, severe involvement of the cervical spine may produce vertebral artery insufficiency and can cause severe dysphagia. Although findings from physical examina- tion often lead to an inaccurate assessment of osteo- arthritis, radiological methods are available for accu- rately assessing the severity of lesions. These methods were used in NHANES II. X—ray films taken in the survey include lateral views of the lumbar and the cervical spine. To avoid any possible X—ray damage to a fetus, lumbar spine X—rays of females were taken only at ages 50 and over. As in previous cycles of the National Health Examination Surveys, certain aspects of the physical examination and medical history were included in the survey to give a picture of the functioning of the joints and the disabilities associated with joint pathology. Consultation on this aspect of the survey was mostly with Dr. William O’Brien of the University of Virginia and Dr. Peter Bennett, National Institute of Arthritis, Metabolism, and Digestive Diseases. The proposal was also reviewed by the Subcommittee of Epidemiology of the National Arthritis Commission. Cardiovascular conditions—One part of the planned NHANES II cardiovascular component was an investigation of cardiac arrhythmia by means of Holter electrocardiogram recordings. Because cardiac arrhythmias are believed to be responsible for most sudden cardiac deaths, this study appeared to provide the opportunity for uncovering epidemiological data of major importance. In clinical practice, the Holter electrocardiogram recorders are attached to the pa- tient, and recordings are made during a 10- or 24- hour period while the patient goes about usual daily activities. To reduce the number of recorders and to lessen the operational complexities in NHANES II, the recordings were to be made over only a 2-hour period, while the examinee was engaged in other parts of the examination. A tryout of the procedure during the pilot test demonstrated that recordings of a good quality could be obtained. However, an expert committee assembled by NCHS and the National Heart, Lung, and Blood Institute to give advice on the proper processing of the tapes was of the opinion that certain parts of the examination, such as the glucose tolerance test, would affect the production of arrhythmias. Unfortunately, the committee rec- ommendations would have necessitated a redesign of the examination that would have added more time to the length of the examination than was judged feasible. When this determination had been reached, there was not enough time left in the plan- ning process to explore alternative proposals, and so the Holter electrocardiogram recordings had to be eliminated from the final NHANES 11 plan. To record the electrocardiogram, equipment that would record three channels of data simultaneously (lZ-standard lead and 3-Frank lead), with immediate conversion from analog to digital format, was used. The electrocardiogram was taken with the examinee resting in a supine position. It should be noted that the computer program available for three-channel processing was much more accurate than those pre- viously available for one-channel processing. To obtain continuing information on hypertension and the status of related medical control efforts in the United States, blood pressures were taken and appro— priate medical history questions were included in NHANES II, as they had been in the previous cycle of examinations (NHANES I). As is mentioned above, determinations were made of cholesterol, triglycer- ides, and high density lipoproteins (HDL). Spirometry.—To provide normative data on pulmonary function similar to that obtained in NHANES I for persons 25-74 years of age, spirometry was performed in NHANES II on individuals 6-24 years of age. As in NHANES I, the data Were recorded on tape, using the same equipment as that used for the electrocardiogram recordings. A computer program was used for processing the data and converting it into the individual parameters that describe pulmonary function. The data can be analyzed in relation to the allergy component and the respiratory data obtained from the medical history and examination. Speech pathology and hearing—The originally planned speech and hearing component of the survey was markedly shortened as a result of consultation and pilot testing. Impedance audiometry had been an important component of the original plan. This procedure was designed to give a measure of the prevalence of middle ear pathology in the United States. During the pilot test, however, difficulties were encountered in getting an adequate airseal; several examinees experienced discomfort; and the test took longer than expected. A decision to discon- tinue the procedure was made after the pilot test, since although additional months of experience with the procedure might have reduced the problems encountered, the entire survey schedule would still have been disrupted. Although impedance audiome- try was dropped from the survey, puretone audiome- try was included for all sample persons 4-19 years of age. It had originally been planned to obtain a speech sample from individuals 4-74 years of age for speech pathology testing, but the instrument finally selected for the speech test was the Stephens Oral Language Test,17 a test using standardized stimulus sentences that had been used to screen children of from 4 through 6 years of age for deficiencies in syntax and articulation. Although the test had been used exten- sively in the 4—6 age group, there was only a very limited experience of its use in older age groups. In NHANES 11 only those 4—6 years of age were tested, since the test had received adequate validation only in that group. Because of substantial oversampling of this age group for the nutrition survey, there were enough children for the resulting data to be useful. Since trained speech pathologists were not avail- able for the survey team, speech recordings of the 15 sentences used in the test were made at the examina- tion site. These recordings could be evaluated subse- quently by a speech pathologist. Considerable effort was expended in designing a recording setup that would produce excellent high-fidelity recordings. In order to provide a standard stimulus for eliciting the speech sample, Dr. Irene Stephens, Associate Pro- fessor, Department of Communicative Disorders, Northern Illinois University, recorded a reading of the speech test on separate Language Master cards. Subse- quent evaluation by Dr. Stephens of about 400 re- cordings taped by the survey demonstrated the fea- sibility of this approach. Blood tests: carbon monoxide, lead and pesticide levels, and venereal disease—The increasing involve- ment of NHANES in studying environmental health factors has reflected the increasing interest in the effect of the environment on health. In NHANES I the major project in the environmental field was the collection and analysis of household water samples for various bulk elements and trace metals. New environmentally related tests were developed for NHANES 11. Air pollution or, specifically, carbon monoxide pollution is an often cited problem in many cities of the United States. Carbon monoxide is a colorless, odorless gas that is a product of incomplete combus- tion and is primarily produced from industrial plants, electric power plants, and automobile exhaust. It has been suggested that carbon monoxide may act to precipitate cardiac symptomatology or episodes by reducing the supply of oxygen to a heart already compromised by coronary disease. Because of the lack of acceptable information on the body burden 13 of carbon monoxide and the potential deleterious health effects due to carbon monoxide air pollu- tion, it was thought to be an appropriate area of study for NHANES 11. Since smoking also results in higher carbon monoxide levels, questions on smoking were included in the survey. Carboxyhemoglobin determinations were done on a half-sample of examinees 3-74 years of age. Special care was taken in quality control for the laboratory determinations, including the use of a reference laboratory. Analysis of data should indicate whether and where carbon monoxide pollution is a significant problem. For many years lead poisoning has been consid- ered an important public health problem, particularly in children. Some important causes of high body levels of lead are contaminated foods, automobile exhaust, and, in children, lead paint. Lead poisoning can produce many adverse effects, including anemia, anorexia, colic, parietitis, hypertension, arteriola degeneration, permanent renal damage, encephalo- pathy, mental retardation, blindness, cerebral atro- phy, glycosuria, visual disturbances, epilepsy, and palsy. In a meeting on trace elements, Dr. Katherine Mahaffey of the Food and Drug Administration gave the following rationale for a survey of lead levels in blood: 0 Available data come either from populations where lead contamination is suspected to be high or from specific control groups where lead con- tamination is expected to be very low. There is no information about the distribution of lead levels in blood for the general US population. 0 The variability with age is not known. 0 With expected large-scale changes in exposure of the population to lead, knowledge of present serum lead levels is needed as a baseline for future studies. Normative information is essential to sub- stantiate regulatory decisions based upon knowl- edge of the biological meaning of high lead levels coupled with available data on lead levels at mini- mal lead exposure. Blood determinations were made on all children through the age of 6 and on a half-sample of all exam- inees over that age. Because of the interest of the Food and Drug Administration in the lead deter- minations, the laboratory cost of the test was under- written by the Bureau of Foods, Food and Drug Administration, and the determinations were made by the Bureau of Laboratories of the Center for Disease Control. The Environmental Protection Agency is author- ized under Public Law 92-516 to monitor not only 14 the environment but human beings as well for evi- dence of pesticide exposure or contamination. The National Human Monitoring Program for Pesticides is operated by the Environmental Protection Agency in partial fulfillment of the legislative mandate. The program’s goal is to determine on a national scale the amount of exposure of the general population to pesticides. It was considered by the Environmental Protection Agency that NHANES II could establish important baseline data on the body burdens of several types of pesticides through blood and urine analysis (appendix III). With the use of chlorinated hydrocarbon pesticides declining and that of organo- phosphate carbamate and phenoxy-type compounds increasing, the capacity to determine human exposure to these new, widely used pesticides has become im- perative. In order to obtain this information, the Environmental Protection Agency offered to under- write the laboratory cost of pesticide level deter- minations of a half-sample of NHANES II examinees 12-74 years of age. A few questions relating to expo- sure to pesticides were added to the questionnaires, and blood and urine specimens were obtained on the half-sample. The Center for Disease Control asked NCHS to include a survey component for venereal disease in NHANES II. The two diseases to be studied were gonorrhea and syphilis. Syphilis testing involved few problems because it had already been included in NHES I (1960-62)1 and the 1974—75 NHANES I Augmentation Survey.5 Inclusion of the serological tests for syphilis on the full sample of persons 12-74 years of age provided opportunity for analysis of the data by population subgroups as well as a comparison with the 1960-62 survey. The serology determina- tions for syphilis included qualitative and quantitative ART, an FTA—ABS, and an MHA—TP. The tests are classified respectively as flocculation, immuno- fluorescence, and hemeagglutination. It is more difficult to test for the presence of gonorrhea. At present there is no serological test for gonorrhea specific enough to be suitable for survey purposes. The standard clinical method for women involves taking an endocervical culture at the same time that a Pap specimen is taken. Experi- ' ence at our initial pretesting operation indicated that many women were unwilling to undergo this proce- dure in a survey setting, and it was therefore decided to omit it from the examination. Instead, a somewhat less sensitive method was used that involved culturing urinary sediments obtained after centrifuging urine specimens. The age range of individuals studied was 12-40 years for males and females, and of those fe- males who received the glucose tolerance test, only those 20-24 years of age had the gonorrhea test done. Sample design for NHANES II The general structure of the NHANES 11 sample design is similar to the designs of NHANES I4 and the first three health examination surveys conducted by the National Center for‘Health Statistical-3a 18 The design is a stratified, multistage, probability cluster sample of households throughout the United States. The process of selecting a sample of persons to be examined is a cascading one that involves the selec- tion of primary sampling units (PSU’s—a PSU is a county or small group of contiguous counties), census enumeration districts (ED’s), segments (a segment is a cluster of households), households, eligible persons, and finally sample persons. The major difference between the NHANES I and NHANES 11 designs is the use of a different set of definitions and stratifica- tion procedures for PSU’s. The details of the NHANES II sampling plan, which resulted in a total of 27,803 sample persons and 20,325 examined persons in 64 PSU’s throughout the United States, are described in the following sections. Design specifications The planning phase for NHANES II is described in a previous section, along with many of the survey objectives. The survey specifications that, directly affected the sample design were as follows: 0 NHANES II should be a probability sample whose target population is the civilian, noninstitution- alized population of the United States (including for the first time Alaska and Hawaii) for persons 6 months through 74 years of age. 0 Subgroups of the population of special interest for nutritional assessment should include pre- school children (6 months - 5 years), the aged (60 - 74 years), and the poor (persons below the poverty level as defined by the US. Bureau of the Census using 1970 census results). These groups should be oversampled to improve the reliability of the statistics for the subgroups. o The total sample size selected for NHANES II should result in approximateh‘ 21,000 examined persons. 0 The number of sample persons selected in each PSU should be between 300 and 600. O The data collection mechanism used in NHANES I should be used in NHANES II with appropriate modifications. Examinations should be conducted in three mobile examination centers. At any time during the survey period (except holidays) two of the centers should be operating in different loca- tions while the third is being serviced or relocated. 0 The total period of data collection should be 3 to 4 years. 0 The average length of an individual examination should be between 2 and 3 hours, but it should vary depending on the age of the examinee. The time required to examine a preschooler should be less than 1 hour, while the time for an adult should not exceed 2% to 3 hours. 0 Approximately one person per sample household should be selected for an examination. The exact number of persons selected for an examination in each household should be determined by applying the sampling rates designated for the different age groups. 0 The size of the PSU should be defined so that it is optimal with respect to cost and response and results in national statistics with an acceptable level of precision. O The survey should be designed so that precise statistics can be produced for the four broad geographic regions of the United States and for the total population by age, sex, race, and income classifications. These sample design specifications took a number of factors into account, including budgetary resources, logistical constraints, time limitations, equipment mobility, and unit operating costs. The specifications 15 also reflected the experience gained from past exami- nation surveys. One of the major survey objectives of NHANES II was the examination of a high percent of sample per- sons. The overall response rates in the examination surveys conducted by NCHS had continually declined since the 1960’s. The response rate for the two surveys of the total US population had declined from 87 percent in the early 1960’s to 74 percent in the early and mid-1970’s. There were multiple reasons for this decline in response—some control- lable and some not. Whatever the reasons, the results of the survey may have been biased because a large proportion of sample persons had not been examined. A design change that was investigated for improving response was the use of smaller geographical areas as PSU’s. The PSU’s used in previous examination surveys had been defined either as a single county or as a group of cdntiguous counties (except in certain parts of New England). Many of the larger PSU’s were defined as standard metropolitan statistical areas (SMSA’s) and often contained several counties. The PSU’s that contained several counties and covered a large area were not ideally suited for an examination survey. Attempting to survey large geographic areas from a centrally located examination center created a number of logistical problems. Some examinees had been asked to travel more than 50 miles to be exam- ined, while others had been asked to travel through very congested areas. Many respondents were reluc- tant to travel under such conditions. The cost of followup visits to the households was also a function of the distance or time from the examination center. An analysis of the response rates for several stands in NHANES I lent further support to these assumptions. The use of smaller areas as PSU’s would reduce both the average distance traveled to the examination center by examinees and the cost of the field work. These considerations were the basis for redefining and restratifying the PSU’s in NHANES II. Definition and stratification of primary sampling units The first-stage sampling units selected in the previous NHES and NHANES I surveys were subsets of the sample PSU’s in the National Health Interview Survey (NHIS). NHIS is one of the NCHS major data collection programs, the design of which is described in an NCHS report19 and in a technical paper20 by the US Bureau of the Census. In NHIS the United States is subdivided into 1,924 PSU’s, with 376 of the PSU’s being selected for the sample. Sixty-five of these 376 sample PSU’s were selected as the NHANES I sample. In redefining PSU’s for NHANES II, the formation of PSU’s for NHIS was reviewed. The PSU’s for NHIS had been defined by the Bureau of the Census and are the same as those used for the Current Population Survey.20 With some slight over- 16 simplifications the following criteria had been used to define PSU’s for NHIS: 0 Each SMSA is a separate PSU. 0 Each PSU is composed of a single county or con- tiguous counties (in some New England States minor civil divisions are used). 0 EachPSU isdefined within the four census regional boundaries. 0 The area of a PSU is less than 2,000 square miles in the West and less than 1,500 square miles else- where. 0 The 1970 population of a PSU is at least 7,500 in the West and at least 10,000 elsewhere. The NHIS PSU’s that contained more than one county were either SMSA’s or had been defined using the last criterion above and represent rural areas. Since rural areas have traditionally had high response rates in the health examination surveys, the only PSU’s considered for redefinition were the SMSA’s. In the NHIS design, about 60 percent of the SMSA’s contained a sufficiently large population to be selected for the sample with certainty (with a prob- ability of one) and are referred to as self-representing PSU’s. In NHIS, 156 of the 376 PSU’s are self-rep- resenting SMSA’s. It was these ‘156 self-representing SMSA’s in the NHIS design that were redefined and restratified for the NHANES II design. For NHANES II, the self-representing PSU’s in NHIS were first split along county boundaries. Within each region, each of the counties was classified as being either a self-representing or a nonself—repre— senting PSU. The PSU’s that were nonself-representing were further combined into homogeneous classes or strata equal in size to the NHIS strata containing nonself-representing PSU’s. The formation of new strata were governed by the following rules: 0 Each new PSU with a population of more than 250,000 in 1970 was classified as a self-represent- ing PSU. In a few special cases, some PSU’s with slightly smaller populations were classified as self- representing. 0 The remaining newly defined PSU’s were com- bined with other PSU’s having similar sociodemo- graphic characteristics to form a number of nonself-representing strata. The PSU’s within a stratum were all located in the same geographic region. 0 Each of the nonself-representing strata was made to have about the same population. The average stratum contained about 350,000 persons in 1970. This method of stratification and the stratifica- tion variables used to form NHIS nonself—representing strata are the basis for the procedures used to form the larger strata for NHANES 11 described in the next section. The regional boundaries used in stratifying PSU’s differ from regional boundaries as defined by the Bureau of the Census. Figure 1 shows the different regional boundaries used in NHANES II and the census. In order to produce regional estimates with approximately equal precision, the NHANES II regions were defined so that they would each contain approximately the same number of sample PSU’s. Because of the small sample size for NHANES II, a regionally balanced design was needed for producing regional statistics. Table A shows the effect of subdividing the self- representing PSU’s in NHIS and redefining the PSU’s by using county boundaries. A total of 397 PSU’s were formed from the 156 self-representing PSU’s: 198 were defined as self-representing, and 199 were defined as nonself-representing and subsequently used to form an additional 43 nonself-representing strata. The average population of a self-representing PSU was reduced from 838,000 to 584,000. In area, the average size of these PSU’s was reduced more than 60 percent, from 2,185 square miles to 855 square miles. Formation of superstrata in NHANES II After the 461 first-stage units (NHIS strata) had been defined, they were further stratified into a total of 64 superstrata for the NHANES 11 design. One PSU was selected from each of the superstrata, and these PSU’s represented the 64 geographic locations visited by the mobile examination centers during the survey period. The stratification and selection of first-stage units in NHANES II is as follows. The number of primary sampling units had to be determined before the number of superstrata could be determined. Because of the design specifications, the maximum number of locations that could be visited during a 4-year period is approximately 80 stands. In order to decide the number of first-stage units to select, a series of design calculations were made. A general description of the process is presented else- where.18 The design model used incorporated such factors as total budget, unit costs, and precision of estimates obtained in previous surveys for a variety of health characteristics. These calculations showed that the optimum number of locations to select was 130, examining 160 persons per stand. One important variable not built into the design model, however, was “down time.” Moving from one location to another requires 1 full week, even when a third examination center can be relocated and hooked up in advance. Time is required for closing the office, packing the equipment, traveling to the new location, and setting up and calibrating the equipment. Locating in 130 different areas over a 3- to 4-year period implies that 2 weeks or less would be spent at each location. This length of time was felt to be too short to achieve required response rates since, in many areas, repeated callbacks are required to achieve a 75-percent exami- nation rate. Previous field experience had indicated that staying in an area for only 2 weeks could reduce response rates by as much as 10 percent. Taking all of the logistical problems into consider- ation led to the selection of a design of 64 primary locations with an average expected number of about 440 sample persons per location. Thus, an examina- tion center would be located in each area for a period of 4 to 6 weeks. With two examination teams being Table A. Number and population of National Health Interview Survey (NHIS) strata before and after subdivision of self-representing primary sampling units, by type of stratum and National Health and Nutrition Examination Survey region [Population estimates are based on 1970 Decennial Census] NHIS strata Rede fined strata Type ““5"” Number Population Average Number Population Average and region . . . . of In population of In population stra ta thousands in th ousan ds strata lb ousands in thousands Sel f-represen ting All strata ......... 156 130,760 838 198 1 15,629 584 Northeastern ....... 50 41,897 838 64 36,795 575 Midwestern ...... 30 31,890 1,063 43 27,831 647 Southern ......... 38 22,706 598 49 19,674 402 Western .......... 38 34,266 902 42 31,329 746 N onsel f—rep resenting All strata ......... 220 72,679 330 263 87,811 334 Northeastern ....... 20 7,144 357 34 12,246 360 Midwestern ....... 61 20,279 332 73 24,339 333 Southern ......... 84 26,752 318 93 29,785 320 Western .......... 55 18,504 336 63 21,441 340 17 Regional Boundaries for the National Health and Nutrition Examination Survey, 1976-80 lLAIIA U.S. Bureau of the Census Regional Boundaries V4 “u“ ~ Q ................... g. , ..... 18 Figure 1. Comparison of regional boundaries for the National Health and Nutrition Examination Survey, 1976-80, with those defined by the U.S. Bureau of the Census employed simultaneously, about 16 stands could be. completed per year. A final comparison was made between the selected design and the design that was optimum with respect to sampling error. It was con- cluded that the final selected design would decrease the reliability of the survey estimates by about 10 percent from those of the optimum design but would substantially reduce the nonsampling component of error. ‘ Because of the small number of primary sampling units, it was decided that the maximum amount of stratification should be used: that the NHIS strata be stratified in 64 superstrata and one PSU be selec- ted per superstratum. The object of stratification is to group the strata with similar characteristics into homogeneous superstrata. A stepwise regression analysis was used to determine which variables would be most effective for collapsing NHIS strata into superstrata. Since NHANES II is a health survey, it would be preferable to use health or health-related variables for stratification. The variables used for stratification must, however, be available at the county level to combine counties or groups of coun- ties into strata. Since health variables were not available at the county level, the stepwise regression analysis was used to study the relationship between the sociodemographic variables that are available for all counties and a set of selected health variables from a previous health examination survey. For the analy— sis, measurements on all the variables listed below were made for each of the sample PSU’s in the first health examination survey. The dependent variables used in the regression analysis were 0 Infant mortality rate and number of infant deaths. 0 Percent and number of persons with kidney trouble. 0 Percent and number of persons with heart trouble. 0 Percent and number of persons with hypertension. 0 Percent and number of persons with high levels of serum cholesterol. The independent variables used in the analysis were Population. Rate of growth. Density (population per square mile). Percent urban. Percent manufacturing. Median income. Percent races other than white. Percent below poverty level. Percent Hispanic origin. Total Hispanic population. 0 Population below poverty level. These variables were defined by the US. Bureau of the Census and included the variables that had previously been used for stratification in NCHS examination surveys. A stepwise regression was performed for each of the dependent variables. When the total number (rather than percent) of persons with a health condi- tion was used for a PSU as the dependent variable, the only independent variable that entered the regression model was population. This demonstrates the importance of either stratifying the PSU’s accord- ing to their population size or selecting the sample PSU’s from strata with a probability proportional to their size. When the stepwise regressions were run for the percent of persons with a given health condition, a number of independent variables entered the regression model. Table B presents the results of the analysis by region. Table C shows the correlation matrix for the health variables and for selected sociodemographic variables. The independent variables that entered the final regression model varied by health condition and among regions. Summarizing the results over all of the health conditions within each region led to some general conclusions: median income was the first or second most important independent variable within each region; the percent of the population below the poverty level was always among the three most important variables in each region; and either “percent races other than white” or “percent Hispanic origin” was among the three most important variables in all but one of the regions. These results were further supported by the correla- tions shown in table C for the total US population. Although the overall correlation between percent Hispanic and the health variables is low for the total United States, percent Hispanic entered the regression model for the Northeastern and Western Regions. ' Because of these results, the following sample design decisions were made and implemented: 0 The first and second most significant independent variables in each region were used as stratification variables. 0 The third most important independent variable in the stepwise regression analysis in each region was used as a control selection variable (described in the next section). 0 The formation of superstrata was performed sepa- rately for self-representing and nonself-repre- senting strata within each region. 0 Population size was used at the first level of stratification within each region. 0 Sixteen superstrata were formed in each region. The superstrata were each about the same size, each containing approximately 3,200,000 persons according to the 1970 decennial census. 19 Table B. Variables in final stepwise regression model, by region Dependen 1‘ variable Independent variables in final regression model Northeastern Region Midwestern Region Southern Region Western Region Infant mortality rate Percent below poverty level Percent races other than white Median income Percent Hispanic origin Percent manufacturing Percent races other than white Percent Hispanic origin Percent races other than white Percent urban Percent below poverty level Median income Percent below poverty level Median income Percent manufacturing Rate of growth Percent Hispanic origin Percent with kidney trouble Percent Hispanic origin Percent below poverty level Median income Percent races other than white Median income Rate of growth Percent manufacturing Percent below poverty level Median income Percent Hispanic origin Percent races other than white Rate of growth Percent manufacturing Percent below poverty level Median income Percent with heart trouble Percent races other than white Percent manufacturing Percent Hispanic origin Median income Median income Rate of growth Percent below poverty level Median income Percent manufacturing Percent urban Percent Hispanic origin Percent with hypertension Rate of growth Percent below poverty level Rate of growth Percent races other than white Percent below poverty level Percent Hispanic origin Median income Percent below poverty level Median income Rate of growth Percent urban Percent races other than white Percent Hispanic origin Rate of growth Percent manufacturing Median income Percent with high serum cholesterol Percent Hispanic origin Median income Percent manufacturing Percent below poverty level Median income Percent below poverty level Percent Hispanic origin Percent races other than white Percent manufacturing Percent below poverty level Median income Infant mortality rate Median income Percent Hispanic origin Rate of growth In accordance with the decision to use the first and second most significant independent variables in addition to population size, the following variables were used as stratification variables for NHANES II: Northeastern Region: Population in stratum Median income Percent below proverty level Midwestern Region: Population in stratum Median income Rate of growth Southern Region: Population in stratum Median income Races other than white plus Hispanics Western Region: Population in stratum Median income Races other than white plus Hispanics The actual formation of the superstrata in NHANES II was performed in two stages. During the 20 first stage the NHIS strata were classified into 64 superstrata according to region, type of stratum (self- representing or nonself-representing), size of stratum (large or small), income (low, middle, or high), percent races other than white plus Hispanics (low or high), and percent below poverty level or rate of growth (low or high). The classification procedure used to form the preliminary superstrata is shown in table D. An important effect of the stratification process was the formation of superstrata containing pnly central cities, suburban counties, or rural coun- ties. Although some precision was lost by splitting the larger SMSA’s, it was hoped that a gain in precision would result from the division of central cities and noncentral cities into separate strata. The final stage in the formation of superstrata was a cluster analysis of the superstrata formed in the first stage. The cluster analysis was performed sepa- rately in each region for the self-representing and nonself—representing strata. Within each of these subdomains the strata were ranked from lowest to highest by population size, area, percent manufac- turing, rate of growth, percent urban, percent races other than white plus Hispanics, median income, and percent below poverty level. For each pairwise Table 0. Correlation matrix for health and sociodemogrmhic variables Percent Percent below Percent races other dran whim Hispanic origin poverty level Median Income Percent manu facturing Percen t urban with hyper- tension widr Infant .. 5?; rag-EB “ 2% Percent Percent Percent with heart trouble Density kidney trouble mortality mm .20 1 .00 1 .00 Percent with high serum cholesterol Percent with kidney trouble Percent with heart trouble Percent with hypertension Infant mortality rate 61 -.09 1 00 .13 1.00 1 .00 Percent manufacturing Percent races other than white Percent below poverty level Percent Hispanic origin Rate of growth Median income Density Percent urban Population .14 .42 .48 .47 .21 .32 .21 Average absolute correlation with health variables combination of strata, the Euclidean distance be- tween the ranks was computed. For stratumA and stratum B, the Euclidean distance is defined as p d(A,B) = g (rm-rm? where p is the number of variables, riA is the rank of the ith variable for NHIS stra— tum A, and r“3 is the rank of the ith variable for NHIS stra— tum B. The smaller the value of d(A,B) the more alike the strata are. The d(A,B) values were then evaluated for each pairwise combination of strata in the NHANES superstrata. Because of the overlap between the variables used for stratification and the variables used to compute the measure d(A,B), the d(A,B) values within a superstratum should be relatively small. This was generally true. A substantial number of individual strata were identified, however, whose sum of d(A,B) values with other members of the superstratum was large. In these cases, an attempt was made to realine the strata within the superstrata so _that the sum of the d(A,B) values over all of the superstrata was minimized for each subdomain. Because of the number of constraints imposed on the stratification process, these adjustments were per- formed manually. This procedure substantially reduced the sum of the d(A,B) values within the superstrata and produced a more efficient stratifica- tion. Cluster analysis was also similarly used for the formation of nonself-representing strata using the newly defined nonself—representing PSU’s. Selection of sample locations The selection of one PSU per superstratum utilized a modified Goodman-Kish“,22 control selection technique. The control selection procedure was used to insure that the selected first—stage sam- pling units represented a “balanced” sample with respect to the control selection variables used. For example, within a region one might want to insure that the final sample PSU’s were distributed evenly across States or across groups of States. This could be achieved by using the “State groups” within a region to control the number of PSU’s selected within each State group. The first step in this selection process involves defining a set of admissible patterns (samples) so that each pattern has an acceptable distribution of PSU’s across the control classes. A pattern or potential sample is admissible if the difference between the number of selected PSU’s is within 1 of the number of PSU’s expected to be .21 Table D. Variables used for stratification in the National Health and Nutrition Examination Survey, by region Stratification variables Region and type Maggi 0f ofstratum strata Income Races other than Rate ofgrowth or white plus Hispanics percent below poverty level Percent below poverty level Northeastern ..................... 16 Self-representing strata ............... 12 Highly urban—New England1 ......... 1 Other urban—New England .......... 1 Large counties (by population) ........ 6 high, medium, low high, low Small counties (by population) ........ 4 high, low, high, low Nonself-representing strata ............. 4 New England places ............... 1 Other ....................... 3 high, medium, low . Rate of growth Midwestern ..................... 16 Self-representing strata ............... 8 Certainty2 .................... 1 Large counties (by population) ........ 4 high, low high, low Small counties (by population) ........ 3 high, medium, low Nonself—representing strata ............. 8 Large strata (by population) .......... 4 high, low high, low Small strata (by population) .......... 4 high, low high, low Southern ....................... 16 Self-representing strata ............... 6 Large counties (by population) ........ 3 high, medium, low Small counties (by population) ........ 3 high, medium, low Nonself-represen ting strata. ............ 10 Large strata (by population) .......... 6 high, medium, low high, low Small strata (by population) .......... 4 high, low high, low Western ........................ 16 Self-representing strata ............... 9 Certainty2 .................... 2 Large counties (by population) ........ 4 ‘high, low high, low Small counties (by population) ........ 3 high, medium, low Nonself—representing strata. . . , .......... 7 Large strata (by population) .......... 4 hiya, low high, low Small strata (by population) .......... 3 high, medium, low 1New England is subdivided into townships rather than counties. Cook County in the Midwestern Region and Los Angeles County (2 stands) in the Western Region were selected into the sample with a probability of 1. drawn from each control class based on its population. The total set of patterns is formed so that the proba- bility of selecting any PSU within a superstratum is proportional to its population. Each pattern within the set is assigned a probability of selection based on the size of the sample PSU’s within the pattern. The sum of the probabilities of selection over all patterns is equal to 1. After the probabilities of selection for the patterns were accumulated, a sample pattern was randomly selected for NHANES II. A detailed de- scription of this controlled selection process is given in an NCHS report.18 Two control selection variables were chosen within each region for NHANES II. The variable “State group” was used in all four regions, and “percent below poverty level” was used in every region except the Northeastern, where “percent races other than white plus Hispanics” was used. Thus, the final sample of PSU’s was drawn so that the sample did not appreciably overrepresent or underrepresent 22 any State group or quartiles representing percent below poverty level or percent races other than white plus Hispanics. The control selection procedure was applied separately within the self-representing and nonself-representing superstrata in every region except the Northeastern, where the control selection was applied to the total region. The control variables used within each region are defined in table E, and the expected and actual number of PSU’s selected from each control class are shown in table F. The “percent below poverty level” or “percent of races other than white plus Hispanics” classes were defined within each region by classifying approximately equal numbers of NHIS strata into quartiles. Classifying the strata into control classes was straightforward for the self-representing strata (one PSU per stratum). The classification of the nonself- representing strata into control classes was more complicated. The PSU’s within each of the NHIS strata are often not all in the same State group, “percent below poverty level,” or “percent races other than white plus Hispanics.” This complication was remedied by selecting a sample PSU within each of the nonself-representing strata. Within each of the original NHIS nonself-representing strata, the NHIS sample PSU was designated as the NHANES II sample PSU. In the newly defined nonself-representing strata a sample PSU was selected with a probability propor- tional to its size. The sample PSU’s within the strata were selected before the sample strata were selected within the superstrata. The sample PSU’s within the nonself-representing strata were then used to classify the strata by State group, percent below poverty level, or percent races other than white plus Hispanics. The selected survey locations for NHANES II are shown in table G. Selection of housing units within sample locations The Bureau of the Census had the responsibility for selecting housing units and sample persons within each of the 64 primary locations. The Bureau of the Census was also responsible for specifying and implej menting the sample design within PSU’s and for over— sampling the subgroups of the population of special interest. Two sampling frames were used to select the sample of housing units within each of the PSU’s. The larger frame was based on the 1970 census of the population. This frame was supplemented by a frame that contained new housing units constructed since the 1970 census. The first stage of design within a PSU involved the selection of clusters of housing units (segments) within enumeration districts (ED’s). An ED is a geo- graphical area containing approximately 300 housing units. In order to oversample persons with low in- comes, the ED’s were sorted into poverty or n_o_n-_ poverty strata as follows: the poverty strata contained ED’s with 13 percent or more of persons below the poverty level, and the nonpoverty strata contained ED’s with less than 13 percent of persons below the poverty level as determined by the 1970 census. The poverty index for households was based on 1969 income, size of family, sex of head of family, age, (under 65 years or 65 years and over) of head of family, and farm or nonfann status. A measure of size was determined for each ED by dividing the number of listed housing units in an ED by 4. Within each stratum the ED’s were then selected with a proba- bility proportional to their measure of size. The number of ED’s selected in each stratum was based on a number of factors that are described below. According to previous experience, it was assumed that a response rate of approximately 75 percent would be obtainable in NHANES II. To examine 21,000 persons, approximately 28,000 persons needed to be selected from the sample households. A mathematical model23 was used to determine the sample size for each PSU and the optimum number to select in the poverty and nonpoverty strata within PSU’s. The sample was allocated in such a way as to minimize the variance of the estimated proportion of persons below the poverty level for a fixed total Table E. Definition of control classes used for the selection of primary sampling units, by region: National Health and Nutrition Examination Survey, 1976-80 Ist variable 2nd variable Region State group State group Quartile Definition of quartile code Percent races other than white plus Hispanics Northeastern A Connecticut, Maine, Massachusetts, New 1 Lowest Hampshire, Rhode Island, Vermont 2 Low—middle B New York 3 Middle-high C New Jersey, Pennsylvania 4 Highest Rate of growth and percent below poverty level Midwestern A Ohio 1 Lowest ' B Indiana, Michigan, Wisconsin 2 Low-middle C Illinois 3 Middle-high D Minnesota 4 Highest E Iowa, Missouri Percent below poverty level Southern A Delaware, District of Columbia, Maryland, Virginia 1 Lowest B Kentucky, Tennessee, West Virginia 2 Low-middle C Alabama, Arkansas, Louisiana, Mississippi 3 Middle-high D Georgia, North Carolina, South Carolina 4 Highest E Florida Western A California 1 Lowest B Oregon, Washington 2 Low-middle C Texas 3 Middle-high D Arizona, Colorado, Idaho, Montana, Nevada, New 4 Highest Mexico, Oklahoma, Utah, Wyoming, Alaska, Hawaii E Kansas, Nebraska, North Dakota, South Dakota 23 Table F. Expected and actual number of sample primary sampling units (PSU's) within control classes, by region and type of stratum [The control classes are defined in table E. The expected number of PSU's in a control class is based on its population] Quartile: represen ting percent below . State group poverty level or percent races Region and type ofstratum other than white plus Hispanics A C D E 1 2 3 4 Northeastern1 Expected number of PSU's ............... 3.86 5.56 6.58 . . . . . . 4.42 3.66 3.97 3.94 Actual number of PSU’s ................. 4 7 . 4 4 4 4 Midwestern Self-representing strataz: Expected number of PSU’s ............... 1.93 2.71 0.80 0.57 0.99 1.05 2.73 2.38 0.84 Actual number of PSU’s ................. 2 1 1 1 1 2 3 1 NonseIf-representing strata: Expected number of PSU’s ............... 1.17 3.57 0.65 0.84 1.76 2.05 1.86 2.02 2.07 Actual number of PSU’s ................. 1 1 1 1 2 2 2 2 Southern Self-representing strata: Expected number of PSU’s ............... 1.94 0.72 0.95 1.02 1.37 1.61 1.57 1.54 1.28 Actual number of PSU's ................. 2 1 1 2 2 2 1 1 Nonself-representing strata: Expected number of PSU's ............... 1.18 2.45 2.83 2.82 0.72 2.44 2.57 2.46 2.53 Actual number of PSU's ................. 1 3 3 2 3 2 3 Western Self-representing stratazz Expected number of PSU's ............... 3.16 0.84 1.55 1.26 0.19 2.01 1.76 2.09 1.15 Actual number of PSU’s ................. 3 1 1 1 2 2 2 1 Nonself-representing strata: Expected number of PSU’s ............... 0.82 0.98 1.92 2.16 1.12 1.80 1.81 1.73 1.65 Actual number of PSU's ................. 1 2 2 1 2 2 1 2 1SeIf-representing and nonself-rapresenting strata combined for control selection. Excludes self-representing superstrata from the National Health and Nutrition Examination Survey, 1976-80. sample size. The allocation procedure employed produced a sample that varied in expected sample size from 281 to 781, with an average of 437 persons per PSU. All but 11 of the sample sizes were within the operationally acceptable range of 300 to 600 sample persons. To conform to the design specifications, the expected sample size for each of these PSU’s was adjusted to fall between 315 and 585 persons. The average ratio of the sampling rate within the poverty stratum to the sampling rate within the nonpoverty stratum was 2.3. This ratio ranged from 1.48 to 5.01 across the sample PSU’s, with 90 percent of the ratios being between 1.5 and 3.0. The households within each ED were clustered into segments in order to reduce the expense of interviewing within ED’s. Results from previous surveys had indicated that a cluster of eight listed addresses would provide an adequate design. To further insure the sampling reliability, clusters of 16 listed addresses were drawn from the sampling frames and then systematically subsampled at a rate of 1 out of 2 to produce a final segment of eight address listings. Using the survey specification that approximately one person should be examined per household (see 24 the next section for the household sampling proce- dure), the expected number of segments needed within each PSU was determined by dividing the PSU sample size by 8. The segments were drawn separately from within the poverty and nonpoverty strata. A systematic sample of segments were then selected across all ED’s, with no more than one segment being selected per ED. The new construction frame was sampled at the same rate as the nonpoverty stratum. Several factors were used to decide the sample size within each PSU. The sample size needed in each PSU was a function of the age distribution within the PSU, the proportion of the population below the poverty level, the expected number of vacant and other types of ineligible units, the expected number of refusals, and the expected number of persons in group quarters. Since the census information did not include the number of persons per segment and was out of date, an additional 15 reserve segments were drawn for each PSU as a precautionary measure. These segments were drawn from both poverty and nonpoverty strata. Because of the complexity of the examination survey and the logistical arrangements that had to be planned in advance, the number of persons selected Table G. Primary sampling units, stand sites, and percent of persons examined, by region: National Health and Nutrition Examination Survey, 1976—80 , , . Percent . . . Percent Primary samp/{ng um ts ) Stand site of persons Primary sampling units Stand site of persons Within reg/ans examined Within regions examined United States ........... 64 731 Southern .............. 16 73.8 1 Northeastern ............ 16 67.4 3:47:32 Szwsicityl """" Atlanta 70.6 Bronx, NY ............. New York City1 61.8 Hampton (city), Va ........ Newport News-Hampton1 79.3 Westchester, NY .......... New York City‘ 51.4 Dade, Fla .............. Miami1 72.8 Manhattan, N.Y. ......... New York City1 56.7 District of Columbia ....... Washington, DC.1 68.7 Bergen, N.J ............. Patterson-C|ifton-Passaic1 63.6 Caddo, La .............. Shreveport1 . 71.4 Allegheny, Pa ............ Pittsburgh1 60.4 Brevard, Fla ............. Cocoa 74.2 Mercer, N.J ............. Trenton 70.5 Poinsett, Ark ............ Marked Tree 84.7 Montgomery, Pa .......... Philadelphia.I 57.8 Bledsoe, McMinn, Meigs, Union, N.J ............. Newark1 61.9 Rhea, Tenn ............ Athens, Pikeville 71.4 Erie, Pa ............... Erie1 77.4 Blount, St. Claire, Ala ....... Oneonta, Pell City 73.3 Orange, N.Y ............. Middletown1 70.8 Hardin, Larue, Nelson, Ky. . . . Elizabethtown, Norfolk (part), Mass ........ Boston1 58.0 Bordstown 76.0 Hartford (part), New Haven Greene, Harrisonburg (city), (part), Conn ............ New Britain,1 Meriden1 69.2 Rockingham, Va. ........ Harrisonburg 70.4 Cumberland (part), Maine . . . . Portland1 70.8 Lafayette, La ............ Lafayette1 69.2 Lycoming, Pa ............ Williamsport 79.0 Floyd, Johnson, Magoffin, Ky. . Saylersville, Prestonburg 69.1 Delaware, N.Y. .......... Oneonta 79.5 Craven, Pitt, N.C .......... Greenville, New Bern 76.0 Bristol (part), Norfolk (part), Banks, Hall, Towns, White, Ga. . Gainesville, Cleveland 74.5 Mass ................. Pawtucket 74.8 Cherokee, York, S.C ........ Rock Hill 78.6 Midwestern ............ 16 73.7 Western ............... 16 77.4 Cook, Ill ............... Chicago1 54.8 Harris, Tex ............. Houston1 65.2 Wayne, Mich. ........... Detroit1 71.4 Santa Clara, Calif .......... San Jose1 74.2 Hamilton, Ohio .......... Cincinnati1 73.2 Honolulu, Hawaii ......... Honolulu‘l 71.8 Marion, |nd ............. Indianapolis.I 70.7 San Diego, Calif. ......... San Die 01 73.4 Hennepin, Minn. ......... Minneapolis-St. Paul1 79.3 Pierce, Wash ............. Tacoma 80.4 Montgomery, Ohio ........ Dayton1 74.2 Sedgwick, Kans ........... Wichita1 76.7 Lake, Ill ............... Chicago.l 65.8 Fresno, Calif ............ Fresno 82.8 Polk, Iowa ............. Des Moines1 73.0 Linn, Oreg .............. Albany 84.1 Dakota, Minn ............ Minnea olis-St. Paul1 83.7 Potter, Randall, Tex ........ Amarillo1 79.7 Racine, Wis ............. Racine 78.1 Yolo, Calif. ............ Woodland 82.6 Greene, Monroe, |nd ........ Bloomington 78.5 Laramie, Wyo ............ Cheyenne 83.4 Coles, Cumberland, Ill ....... Mattoon 74.3 Bingham, Idaho .......... Blackfoot 88.4 Ionia, Montcalm, Mich ....... Greenville 80.6 Hickory, St. Clair, Mo ....... Osceola 75.8 Richland, Ohio .......... Mansfield1 74.8 Parmer, Tex ............. Bovena 85.4 Cheboygan, Emmet, Mich.. . . . Cheboygan 78.5 Los Angeles (part), Calif ...... Los Angeles1 62.4 New Madrid, Stoddard, Mo. . . . Baxter 73.6 Los Angeles (part), Calif ...... Los Angeles1 69.5 11970 standard metropolitan statistical area containing the survey location. Some of the SMSA's have been redefined since 1970. for examination had to be carefully controlled. A sequential sampling procedure known as “Perkins’ Stop Rule” was used to insure that the number of persons selected in each PSU was within 15 of the expected number of sample persons. Perkins’ Stop Rule, as described in a Bureau of the Census publica- tion,24 is an unbiased procedure for determining both the number of reserve segments to use in each PSU and when to stop interviewing sample persons within selected households. Since the expected number of persons in each PSU is between 315 and 585, the stop rule also insures that the actual number of sample persons in each PSU is between 300 and 600. For NHANES II, the number of sample persons ranged from 306 to 598 with an average of 334 per PSU. Selection of sample persons After the sample segments had been identified and assigned to interviewers, a sample of persons to be examined from individual households was selected. The sample was selected so that young and old age. ' groups were oversampled and so that approximately one person was selected per household. The Bureau of the Census evaluated a number of alternative sub- sampling schemes within the household with respect to these objectives. The subsampling procedure that best satisfied both of these survey objectives was one that selected 3 out of every 4 persons who were 6 months through 5 years of age or 60 years through 74 years of age and 1 out of every 4 persons who were 6 through 59 years. The sample person selection sheet is shown in figure 2. Once in the household, the interviewer listed everyone who lived in the household in a specified order. The number of persons within each age group was indicated, and letter codes were used to select persons from each of the three age groups for the sample. The letters used to sample persons from each age group are shown in figure 2. After a random start, 64 three-letter combinations were systematically 25 assigned to the household questionnaires for each PSU in the Bureau of the Census regional office. Three letters were circled on each questionnaire before it was assigned to an interviewer. For example, suppose that the letters “A,” “K,” and “W” were circled on the household questionnaire for a family of four: one baby 9 months old, two adults of ages 30 and 31, and one adult aged 66. The number of persons in each of the three age groups (see figure 2) is 1, 2, and 1, respectively. The letters “A,” “K,” and “W” indicate that the interviewer should select the first person in the age group 6 months to 5 years, the second person listed in the 6-59 years age group, and the second person in the 60-74 years age group, as sample persons. In the example, since there was no secondperson’ listed in the 60-74 years- age group, the 9-month-old son and the 31-year-old wife were selected as sample persons for the examination. Io. VII-av is the none at the head of thin hounnold? Enrer name on lust line, Be sure to list all persons in (he correct order. 0. Are any .1 the persons in this household now on lull-time ii. who? I" the nonm ol all other persons who live here? LIS! all persons who live here. e. l have lined (Read names). It then onyone elu staying here new, meh u lrlends, relativu, or room-n? C] d. "an I missed anyone who USUALLY live: here he is new away iron home? .................... I. Do any of the people in this household have a horn- anywhere else? ...... Yes ' No 8% ‘ Apply memory membership rules. mm duty with .5. Armed Fm" .l m United 5mm ..... r3 Yes——> Lme(s) (Delete) 14’ No «1°37; "'t'fil: -- “l" mm A 0 one o . o -- s I ? 3: Name mm. middle .muol. last) Use (M w the“ Em'fsfé :20" ClIClO lme number or W‘" “‘F “"4 "1' Cime SP‘s household respondent (or (anSlSllle 1.. 21.. 2:. u. 2°- neunonwp Monm Dly Vent A" ger- ‘9‘“ :2; Kabev‘l‘ E. shnflv A‘ea 4/ 10 07 ’7’? 3 0 X M M 5. 5mm wxfg Is’ 29 ’7’? 3/ (>9 Pad 5 fin/7% 50/; J} // 7i 7m: (3) Ear/ 6'. Jones fafiew w- /m 06 34 I3 44 X omuom.uqk~l— SAMPLE PERSON SELECTION PERSONS PERSONS PERSONS 6 months :5 years 6 years - 59 years 60 years — 74 years (A) , v lst. 2nd. 3rd, Srh. 61h, 7m lsr. 5rh. 9th lst, 2nd. 3rd. 5th, 61h, 7th B (:9 v? 2nd, 3rd. 4th. 6th. 71h. 31h 2nd, 62h. IOrh 2nd. 3rd. 4th, 61h. 7th. 81h C L X lsr, 3rd, 4th, 5th. 7th. 8th 3rd, 7th, llrh Isr, 3rd. 4th. Srh. 7th, 8th In. 2nd, 4rh,DSrh. 61h. 8th 4th. 8er“ |2rh lst. 2nd. 4th.ZSth. 6th, 81h CHECK ITEM A > K D No Sample Personl s) - Explain to respondent why no further questions. Go to page I, llem l3. Sample Person“) — Fill Medical History Notes E Figure 2. While of a sample person selection sheet used in the National Health and NutriTtEhr Examination Survey, 1976-80 Operational plan Stand sequencing and scheduling As in previous cycles of NHES and NHANES, the scheduling of stands (examination locations) for NHANES II was arranged so that the North was avoided in winter. This was done because of opera- tional problems that would otherwise have resulted. To the extent that any of the items of data collected by the survey were subject to seasonal variation, this procedure may have resulted in some bias, but since the survey was designed more to measure the preva- lence of chronic conditions rather than acute manifes— tations of conditions, seasonal variation was not considered to be a major factor. Another important consideration in the sequenc- ing of stands was economy in operation. Efforts were made to insure the minimum amount of travel by sequencing examination locations with regard to geographic proximity. At each location, the regular procedure involved the following sequence of advance arrangements: US. Bureau of the Census interviewing in the household, mobile exam center setup, dry-run examinations, and, finally, follow—back with sample persons by Health Examination Representatives when indicated, and regular examinations of the sample persons. The number of weeks allotted for examina- tions was dependent upon the expected sample size at a particular stand but varied between 4 and 6 weeks. Advance contacts and logistics Before household interviewing could begin in a sample area, contacts with professionals and the public and logistical arrangements were necessary. It was the policy of the survey to contact the Public Health Service representatives in the Department of Health and Human Services (formerly the Department of Health, Education, and Welfare) regional offices, the State andlocal health authorities, and the medical, dental, and osteopathic professional organizations in the States and communities. This was done to ac- quaint them with the NHANES objectives and methods of operation, including the local schedule of operations. School officials were also notified because of the necessity of requesting release from school for the examination of school children. This notification usually consisted of a letter announcing the survey, the local areas to be sampled, and the dates of survey operations, along with a brochure describing the survey, mailed 2 months before examinations were scheduled to begin. The letters to local health au- thorities included a request to provide NHAN ES with a listing of local and State health agencies and clinics to which NHANES examinees who did not have current medical resources and who required medical care could be referred, or to which a report of the examination findings could be sent. Personal visits by NHANES medical staff were made to any health agencies or societies requesting them. A general news release explaining the program was prepared for each sample area and distributed to local news media. The release was timed to coincide with the start of the Bureau of the Census interview- ing. As a result, local newspapers at most of the locations published items concerning the program. Special efforts were also made to obtain television and radio publicity for the survey. Any pictures taken for these efforts used NHANES staff as subjects, because pictures of examinees would have involved a loss of confidentiality. Sample households with known addresses were sent an “advance” letter by the Bureau of the Census several days before interviewing began. This letter informed the household members that a Bureau of the Census interviewer would call at their home within the next few days in connection with a survey being conducted in the area by the Public Health Service. Six to eight weeks before the start of examinations at a particular location, a member of the NHANES field staff, the Field Operations Manager, visited the sample area to make physical arrangements for the mobile examination center and the administrative 27 offices, to meet personally with local health and school officials, and to initiate the many logistical actions required for the survey. Selection of a site for the mobile examination center and arrangements for electricity, water, sewerage, telephone, and trans- portation services were also made on this initial visit to the area. Household interviewing and appointment process Trained Bureau of the Census personnel con- ducted the household interviews to obtain household composition, demographic, and other data. At this initial visit the census interviewer determined which members of the household were to be selected for inclusion in the sample. The census interviewer explained the survey, asked a series of medical history questions of the prospective examinees, and made appointments for the selected sample persons willing to come in for the examination. As an incentive to participate in the examination, the sample persons were told that they would receive $20 for any incon- venience caused them because of their participation. The census interviewer also obtained written consent for the examination of minors and written authori- zation to obtain additional information from the records of physicians, hospitals, schools, and State registry offices. The census interviewer informed sample persons that reports of significant findings would be sent to their physicians or clinics if they so desired. Ah individual who did not make an appointment at the time of the visit by the census interviewer was subsequently visited by a Health Examination Repre- sentative, who explained the program more fully, using photographs and a film strip. The Health Exam— ination Representative answered any questions about how the sample was selected or the examination conducted and about what was included in the exam- ination. Points that were stressed included personal benefit to be derived from the examination, contri- butions to medical research, and civic pride. In addi— tion, it was stressed to sample persons that they were statistically chosen for the survey and no one else could be substituted for them. By carefully explaining details of the examination, the representative at- tempted to allay any fears or anxieties about it. This additional effort resulted in scheduling for examina- tion many of the persons from whom the census interviewer had been unable to obtain appointments. The typical weekly examination schedule called for five morning sessions (including Saturday), three afternoon sessions (including Saturday), and two evening sessions. Individuals receiving the glucose tolerance test were scheduled for the morning sessions only. Sample persons could elect to drive themselves to the examination center, but use of ataxi for which arrangements had been made was encouraged. Trans- 28 portation costs were paid by NHANES under either arrangement. Appointments for persons who for one reason or another had canceled or broken their appointments or who had not been available for taxi pickup at the scheduled time were rescheduled if possible. Any necessary rescheduling was accomplished by the health representative as soon as possible, preferably the same day, a policy that helped rein- force in the sample persons’ minds the importance placed on their participation. Examination center and staff As in the previous examination programs, exam— inations were carried out in specially designed mobile examination centers (figure 3), which were moved from location to location in a predetermined fashion so that a sample of the civilian noninstitutionalized population was administered a standardized set of questions, examinations, and laboratory tests in comparable settings by a fully trained staff. Each mobile examination center consisted of three trailers, each 45 feet long and 8 feet wide. The sets of trailers constructed for NHANES I had been refitted with some interior modifications and used for NHANES II. They were set up side by side on a level hard surface area and connected by enclosed passageways. The trailers themselves were then further leveled to enable connection of the plumbing and proper alinement of the passageways. Heating and air-conditioning units Body Qrulo measurements room room : ometvy Wash ' Audl- sun room sun X .n‘fflnc. Physlcal Wash oxamlnatlan I‘H-matology— room Dark X‘ "W room ilntorvlow room Pulmo- [ju Waltlng r r or Labo am y nary W area lmervlow room we m [‘t“" "9 Examlnee entrance Figure 3. Mobile examination center helped provide a standardized environment in which to conduct the examinations and perform laboratory procedures. For NHANES II the trailer setup was as follows: The first trailer contained the waiting room where the sample persons were checked in by a coordinator. The coordinator’s main function was to assign the examinees to the staff members conducting different parts of the examination in such a way as to minimize the examinees’ total waiting time. To the side of the waiting room were two small rooms used for dietary interviews. Another slightly larger room in this trailer was used for administering the allergy test and conducting health interviews. A laboratory was equipped with a Coulter Counter, a hemoglobinom— eter, an incubator, a microhematocrit centrifuge and reader, a centrifuge, a refrigerator and freezer, a microscope, and a laminar flow table. The room where respiratory testing was done was located next to the laboratory and contained a spirometer, a two-channel paper recorder, and an oscilloscope. The spirometer was connected to a Marquette electrocar- diogram recorder located in the third trailer. The second trailer had an X—ray room containing an X-ray machine, reciprocating buckey, and table. This room was used for chest, back, and neck X-rays. Adjoining the X-ray room was a dark room. An X-omat for developing X-ray film automatically was in an open space adjacent to the dark room. The walls of the open space contained X-ray viewing boxes. The second trailer also contained one of the two wash- rooms used for dressing and obtaining urine speci- mens. In the second trailer there were two other rooms. One of these rooms contained an examining table and a mercury sphygmomanometer, and the other a table and equipment for drawing blood. The third trailer contained a soundproof room used for hearing tests. At test frequencies, the back- ground noise level was below 35 decibels relative to American Standards Association audiometric zero (National Bureau of Standards). This room contained an audiometer with masking capability and earphones for pure-tone audiometry. It also contained a Revox tape deck, a condenser microphone, and a playback machine for the Stephens Oral Language Screening Test. Adjoining the audiometry room was a wash- room. Another room contained the Marquette electrocardiogram recorder and a table. Electrocar- diograms as well as spirometries were recorded on tape there. The final examination room was the body-measurement room. It contained a large and very accurate weight scale, a set of calibration weights, a device for measuring heights, an examining table for measuring sitting heights, and a variety of anthro- pometric instruments. The third trailer also included a staff room. There was storage space both within and under the trailers. The field staff necessary to carry out the opera- tion of the survey consisted of three groups. The first one was the team of census interviewers and their supervisor. The second group consisted of admini- strative staff and Health Examination Representatives. The usual complement was a field operations manager, field management assistant, one or two local part- time employees, and five Health Examination Re- presentatives. The third group was the examining staff, operating within the mobile examination center, consisting of a physician, a nurse, two dietary interviewers, three health technicians, two laboratory technicians, and a coordinator. Everyone on the examining staff had been thoroughly trained to conduct the standardized procedures. All the field staff except the physician were civil service employ- ees; the physicians ‘were employed on long-term personal services contracts. The administrative staff was responsible for all procedures involved in process- ing examinees prior to their entry in the exam center. The health technicians conducted most of the testing, including taking X-rays, electrocardiograms, body measurements, and spirometries; and audiometry, the allergy exam, and the administration of question- naires. The laboratory technicians performed all the laboratory work that had to be done on site, includ- ing preparation of blood and urine specimens for shipment. The nurse was mainly occupied with drawing blood. Examination process and medical reports Each examinee was assigned to whatever examin- er happened to be free at the time. However, certain restrictions were built into the examination. For example, since oral glucose intake induces changes in electrocardiogram patterns, the electrocardiogram had to be done before the glucose tolerance test. Similarly, because of a possibility that an occasional allergy test might affect pulmonary function, spi- rometry was done before the allergy test. The require- ment of a concentrated urine for microscopic exami- nation necessitated urine collection before the glucose tolerance test. It was also desirable to expedite blood samples in order not to stretch out the labora- tory work day unduly. A report of medical findings, including laboratory results, was sent to the examinee’s personal physician or other source of medical care designated by the examinee. Any condition that in the opinion of the examining physician required immediate medical attention was immediately reported by phone to the personal physician or medical care facility designated by the examinee. A chest X-ray and a copy of the electrocardiogram were sent with the report. Some findings were not included on the regular report be- cause they were not available at the time the report was mailed. For example, the back and neck X- rays were read by 'three rheumatologists at a later 29 time, so the results of their assessment were not immediately available. If some degree of pathology was found, these results were reported to the ex- 30 aminee’s source of medical care when they became available. Quality control Measurement error, an important concern in any survey, was even more so in one as complex as NHANES. Minimizing measurement error required a considerable amount of careful effort. Before the collection of data, it was necessary to define precisely what was to be measured and to describe clearly how the measurements were to be taken. Before the survey began, the NHANES staff, assisted by advisers, delineated the necessary definitions and instructions, which were incorporated into a staff instruction manual covering all procedures. Intensive specialized training was given to all staff members in the specific procedures performed by them in the survey. Periodic retraining was provided in order to achieve consisten- cy over the entire survey period. An important requirement for quality control is the proper calibration of instruments. Among the instruments calibrated were the spirometers, audi- ometers, earphones, electrocardiogram recorders, speech recording equipment, laboratory equipment, scales, and body measurement equipment. The instruments were calibrated at different intervals, that is, with each examination, daily, weekly, or before the beginning of each stand location. Calibration of a particular instrument might be done in more than one fashion: for example, the spirometer was calibrated both electronically and pneumatically. Calibration of the audibméters was done both in the field and also more thoroughly at a central laboratory to which they were sent on a rotating basis. Preventive maintenance was also quite important in keeping the equipment running properly. Prompt repair of the instruments was essential in order to avoid excessive loss of data. The staff biomedical engineer was invaluable in providing for the proper functioning of the equipment. The engineer also played a major role in designing the equipment setup, arranging for its installation, and working out any difficulties that developed in the system. Several methods were used to obtain adequate quality control. For certain procedures such as those involved with height, weight, X—rays, spirometry, electrocardiographs, and speech, “hard documents” were produced, the quality of which could be evalu- ated and the significance assessed at a central location. For example, X-ray films were evaluated for readabil- ity, interpreted by expert readers, and subjected to replicate readings. Replicates involved having the same part of the examination, for example, body measurements, performed independently at different times by two observers. Another more experienced observer, such as a supervisory technician, could be used as the standard. Replicates were a powerful tool in demonstrating interobserver differences. For biochemistry tests, replicates took the form of a duplicate pair of specimens being sent, one of them under a “dummy” number, to the same labora- tory. Another method of quality control in the evalua- tion of the different procedures was to compare mean values and frequency distributions by stand location and by individual observers. If there was an unusual set of results in one location, this could be investigat— ed. Similarly, if one of the technicians consistently obtained higher or lower values than the others, this could also be investigated. All recording forms were reviewed by the examin- ing staff before the examinees left in order to detect errors such as omission of data. Samples of the forms were checked again, more thoroughly, at headquarters. If the staff was making a systematic error, it could be detected, and proper remedial action taken. The performance of some of the field staff could also be checked by tape recordings. At every location, each dietary interviewer recorded two complete interviews on randomly selected subjects. The re- corded interviews were evaluated later at headquar- ters for adherence to established procedures. Retention of a reserve container of serum pro- vided an opportunity for repeating and possibly cor- recting biochemical assessments. If an error was detected in the processing of a batch of serum, or an unusual value was observed, a reserve supply of serum was available for many sample persons to provide 31 analytical results, either to replace the unsatisfactory data or to verify the unusual value. In all laboratories to which specimens had been sent for analysis, standard quality control procedures were used. These included blind quality control specimens from known control pools. For quality control samples, several statistics were produced, including trend lines, plots, means, and standard deviations. Known test materials were used; and all reagents, calibrations, and the like were logged. Deter- minations were repeated for specimens showing extreme values. A useful procedure for quality control of labora- tory data was implemented in 1978. This procedure was as follows: from a frequency distribution of values, the value closest to the 75th percentile was selected. For example, suppose fasting blood glucose data showed .246 of the population with values of 98 or over. In a run of 13 specimens, if one were to find 9 specimens with values of 98 or over, the chances of this happening according to the cumula- tive binomial distribution is .0009. This is quite unlikely, and the matter would be carefully looked into. A similar procedure was followed with a low cutoff value at or near the 25th percentile. In fact, the glucose determinations showed only four runs with a probability of less than .01 out of a total of 240 (including both high and low cutoffs). Since on a chance basis five runs might have been expected, this suggested that the procedure was in control during this period. A major errdnwasfim’m’ai NHES surveys—tel, control and reduce the magnitude of the nonresponse. If the nonrespondents in a survey differ from res- pondents with respect to the measurements being made, the survey results will be biased. The potential for a nonresponse bias is much greater when response 32 rates are low. A_ number of steps taken to reduce nonresponse in NHANES II have already been dis- cussed. The size of the primary sampling units was reduced primarily to decrease the logistical problems of sample persons coming to the mobile examination centers. Much of the advance publicity was directed to improving the overall response rate in a commu- nity. The extra efforts of the Health Examination Representatives to schedule appointments and to arrange transportation to the Mobile Examination Centers were very important in the achievement of acceptable response rates. Several reports have been written that discuss cooperation in National Health Examination Surveys and the factors related to response.2 5 '2 8 The response rates for both NHANES I and NHANES II were between 70 and 75 percent—lower than the response rates obtained in previous NCHS examination surveys. Concern over the lower response rate in the NHANES programs resulted in two studies’ being conducted to determine the effect of paying respondents to participate in NHANES. The first study was conducted in San Antonio, Tex., in 1972. The findings from that study showed that the offer of a payment of $10 to sample persons to participate in NHANES significantly improved the response rate.29 As a result of that study, a payment of $10 was rou- tinely offered to all sample persons for participating in the examination. A second study on the effects of remuneration to sample persons was conducted in two locations in 1978. A slightly more elaborate design was used to study the relationship between the amount of the payment offered sample persons to participate in the examination and the number of sample persons in the household. The results showed that the total amount of remuneration in a household had a significant positive effect on response.3 0 Pilot testing Pilot testing was much shorter in NHANES II than in NHANES I. The first pilot test was in Atlanta, Ga., from November 17 through December 19, 1975. Center for Disease Control personnel and their fam- ilies were the examinees. The location was next to the Center for Disease Control in order to have ready access to assistance in carrying out the complicated laboratory procedures. The second pretest was held in another part of the Atlanta metropolitan area from January 21 through February 12, 1976, using a pop- ulation sample of the area selected by the U.S. Bureau of the Census. The NHANES 11 survey began examinations at its first regular location in Miami, Fla., on February 19, 1976. 33 Plans for analysis and publication of data Producing reports of findings involves the follow- ing steps: 0_ Sometimes, as with X-rays, there must be further processing to produce the data unit that is to be tabulated. This type of processing is done under contract concurrently with data collection if resources permit. Data must be reduced to machine-readable form. Data must be edited and validated. Data must be analyzed. Reports must be written, edited, and printed. In addition, before any analysis can take place, the sampling weights, that is, the designated number of people a sample person represents in the popula- tion, must be determined. For selected measures, imputation procedures for item nonresponse must be developed and reviewed by consultants. The procedure used before 1977 was to allot a certain number of years after completion of a survey in which NHANES analytical staff could publish series reports based on the survey. After that, a set of computer tapes containing the edited data was pre- pared for the use of outside investigators in universi- ties, other government agencies, and so forth. The procedure used since 1977 has been to release for outside use all completely edited, validated, and documented tapes, whether or not NCHS has pub- lished reports based on the data. It was planned to have a series of edited tapes containing the NHANES II data available for purchase from 1 to 2 years after completion of the NHANES II survey. In general, descriptive, analytical, and methodolog- ical reports are published by the National Center for Health Statistics in Vital and Health Statistics, series 1, 2, and 11. To a lesser extent, information is made available in journal articles and in papers presented at professional meetings. The reports are written by NCHS staff, staff of Federal agencies collaborating on data collection, and experts who are not Federal . employees. In addition, to expedite publication of more detailed analyses of selected topics covered in the data collection, NCHS plans to support to a limited extent competitively awarded contractual analyses and report-writing efforts. A limited number of special tabulations and analyses are furnished on request to various individuals and groups both inside and outside the Government. Procedures and methods manuals are made avail— able upon request about a year after the surveys are completed or concurrently with the release of micro- data tapes. In this way the data can be evaluated, and the methodology employed by NCHS in NHANES can be utilized by others. References 1National Center for Health Statistics: Plan and initial pro- gram of the Health Examination Survey. Vital and Health Statistics PHS Pub. No. lOOO-Series l-No. 4. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 2National Center for Health Statistics: Plan, operation, and response results of a program of children’s examinations. Vital and Health Statistics. PHS Pub. No. lOOO-Series l-No. 5. Public Health Service. Washington. U.S. Government Printing Office, Oct. 1967. 3National Center for Health Statistics: Plan and operation of a Health Examination Survey of U.S. youths 12-17 years of age. Vital and Health Statistics. PHS Pub. No. 1000-Series l-No. 8. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1969. 4National Center for Health Statistics: Plan and operation of the Health and Nutrition Examination Survey, United States, 1971-1973, by H. W. Miller. Vital and Health Statistics. Series l-Nos. 10a and 10b. DHEW Pub. No. (PHS) 79-1310. Public Health Service. Washington. U.S. Government Printing Office, Jan. 1977. 5National Center for Health Statistics: Plan and operation of the HANES I Augmentation Survey of adults 25-74 years, United States, 1974-1975, by A. Engel et al. Vital and Health Statistics. Series l-No. 14. DHEW Pub. No. (PHS) 78-1314. Public Health Service. Washington. U.S. Government Printing Office, June 1978. 6National Center for Health Statistics: Current listing and topical index to the Vital and Health Statistics Series, 1962- 1978. DHEW Pub. No. (PHS) 79-1301. Public Health Service. Washington. U.S. Government Printing Office, Apr. 1979. 7National Technical Information Service, 5285 Port Royal Road, Springfield, Va. 22151, telephone (703) 557-4650. 8McDowell, A. J .: Health examination surveys —— in theory and application, in P. Armitage, ed., National Health Survey Systems in the European Economic Community. Proceedings of a conference held in Brussels on Oct. 6-8, 1975. Commis- sion of the European Communities, EUR 57476, 1977. 9National Center for Health Statistics: Eighth Revision Inter- national Classification of Diseases, Adapted for Use in the United States. PHS Pub. No. 1693. Public Health Service. Washington. U.S. Government Printing Office, 1967. 10National Center for Health Statistics: Glucose tolerance of adults, United States, 1960-1962, by T. Gordon. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 2. Public Health Service. Washington. U.S. Government Printing Office, May 1964. 11National Center for Health Statistics: Blood glucose levels in adults, United States, 1960-1962, by C. C. Garst. Vital and Health Statistics. PHS Pub. No. 1000-Series 11-No. 18. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1966. 12National Center for Health Statistics: Blood pressure as it relates to physique, blood glucose, and serum cholesterol, United States, 1960-1962, by C. duV. Florey and R. M. Acheson. Vital and Health Statistics. PHS Pub. No. IOOO-Series 11-No. 34. Public Health Service. Washington. U.S. Govemment Printing Office, Oct. 1969. 13National Center for Health Statistics: Selected examination findings related to periodontal disease among adults, United States, 1960-1962, by J. E. Kelly and A. Engel. Vital and Health Statistics. PHS Pub. No. 1000-Series ll-No. 33. Public Health Service. Washington. U.S. Government Printing Office, Sept. 1969. 14National Center for Health Statistics: The one-hour oral glucose tolerance test. Vital and Health Statistics. Series 2-No.‘ 3. DHEW Pub. No. (HRA) 74-1271. Health Resources Admin- istration. Washington. U.S. Government Printing Office, Aug. 1973. Reprinted. 15Nil, A. A. J .: A population study of urinary trace disease 11. Acta. Med. Scand. 194: 529-534, 1973. 16Burrows, B., Leborwitz, M., and Barbee, R. A.: Respiratory Disorders and Allergy Skin Test Reactions. Ann. Intern. Med. 84(2): 134-139, Feb. 1976. 1'7Stephens, 1.: Stephens Oral Language Screening Test. In- terim Publishing Co., Dec. 1977. 18National Center for Health Statistics: Sample design and estimation procedures for a National Health Examination Survey of children, by E. E. Bryant, J. T. Baird, and H. W. Miller. Vital and Health Statistics. Series 2-No. 43. DHEW Pub. No. (HSM) 72-1005. Health Services and Mental Health Administration. Washington. U.S. Government Printing Office, Aug. 1971. 35 19U.S. National Health Survey: The statistical design of the Health Household-Interview Survey. Health Statistics. PHS Pub. No. 584-A2. Public Health Service. Washington. U.S. Government Printing Office, July 1958. 20U.S. Bureau of the Census: The Current Population Survey: Design and Methodology. Technical Paper 40. U.S. Depart- ment of Commerce. Washington. U.S. Government Printing Office, Jan. 1978. 21Goodman, R., and Kish, L.: Controlled selection—a tech- nique in probability sampling. J. Am. Statis. A. 45(251):350-373, Sept. 1950. 2 2Kish, L.: Survey Sampling. New York. John Wiley and Sons, Inc., 1965. ”U.S. Bureau of the Census: Determination ofPoverty/Non- poverty Strata and Optimal Sample Allocation, HES Cycle IV. Memorandum from Paul Tomlin to Gary Shapiro, Oct. 26, 1972. 24U.S. Bureau of the Census: Technical Notes No. 3. Wash- ington, DC. 1970. 2 5U.S. National Health Survey: Attitudes toward co-operation in a Health Examination Survey. Health Statistics. PHS Pub. No. S84-Series D-No. 6. Public Health Service. Washington. U.S. Government Printing Office, July 1961. 26National Center for Health Statistics: Cooperation in Health Examination Surveys. Vital and Health Statistics. PHS Pub. No. lOOO-Series 2-No. 9. Public Health Service. Washington. U.S. Government Printing Office, July 1965. 36 27National Center for Health Statistics: Factors related to response in a Health Examination Survey, United States, 1960- 1962, by H. Miller and P. Williams. Viral and Health Statistics PHS Pub. No. lOOO-Series 2-No. 36. Public Health Service. Washington. U.S. Government Printing Office, Aug. 1969. 28National Center for Health Statistics: Quality control in a National Health Examination Survey, by W. L. Schaible. Vital and Health Statistics Series 2-No. 44. DHEW Pub. No. (HSM) 72-1023. Health Services and Mental Health Admin- istration. Washington. U.S. Government Printing Office, Feb. 1972. 29National Center for Health Statistics: A study of the effect of remuneration upon response in the Health and Nutrition Examination Survey, United States, by E. E. Bryant, M. G. Kovar, and H. Miller. Vital and Health Statistics. Series 2-No. 67. DHEW Pub. No. (HRA) 76-1341. Health Resources Administration. Washington. U.S. Government Printing Office, Oct. 1975. 30Findley, J. 8., National Center for Health Statistics, and Schaible, W. L., U.S. Bureau of Labor Statistics: A study of the effect of increased remuneration on response in a Health and Nutrition Examination Survey. Paper presented at the American Statistical Association Meeting, Survey Research Methods Section. Houston, Aug. 1980. Appendixes Contents I. Examination components by age groups ..................................................... 38 II. Blood and urine assessments by specimen types and age groups ...................................... 39 Ill. Pesticide residue and metabolite determinations ................................................ 40 IV. National Center for Health Statistics and Center for Disease Control staff involved in the planning, development, and operation of NHANES II ............................................................... 41 National Center for Health Statistics ...................................................... 41 Center for Disease Control .......................................................... ‘ . . 42 Data collection forms for NHANES ll ....................................................... 43 NHANES Household Questionnaire ...................................................... 43 Medical History Questionnaire, Ages 6 Months-11 Years ......................................... 51 Medical History Questionnaire, Ages 12-74 Years ............................................. 68 Health History Supplement, Ages 12-74 Years ............................................... 95 Dietary—24 Hour Recall and Dietary Frequency .................... , .......................... 114 Dietary Supplement, Ages 12-74 Years .................................................... 116 Medications/Vitamin Usage ............................................................ 118 Behavior Questionnaire, Ages 25—74 Years .................................................. 119 Control Record .................................................................... 122 Body Measurements ........................... ' ...................................... 123 Audiometry (Air), Ages 4-19 Years .......................................... - ............. 1 25 Allergy Testing .................................................................... 126 Spirometry, Ages 6—24 Years ........................................................... 127 Liver Function Test, Ages 35-74 Years .................................................... 128 Glucose Challenge, Ages 20-74 Years ...................................................... 129 Speech Pathology Test, Ages 4-6 Years .................................................... 130 Physician’s Examination, Ages 6 Months-74 Years ............................................. 131 Interviewer Information Card Booklet ..................................................... 140 37 Appendix I. Examination components by age groups 6‘ months-2 years 3—17 years 12- 79 years 20-74 years (bile acids test group) 20-74 years (glucose tolerance test group) Body measurements Physician exam Venipuncture Dietary interview Urine: 6-11 years only Body measurements Physician exam Venipuncture Dietary interview Audiometry: 4-11 years only Speech test: 4-6 years only Allergy test: 6-11 years only Spirometry: 6-11 years only Urine Body measurements Physician exam Venipuncture Dietary interview Audiometry Allergy test Spirometry Urine Body measu rements Physician exam Venipunctu re Dietary interview Allergy test Spirometry: 20-24 years only Electrocardiogram: 25-74 years only Chest and neck X-rays: 25—74 years only Back X-ray: 25-74 years for men; 50-74 years for women ’Bile acids test: 35-74 years only Urine Body measurements Physician exam Venipuncture Dietary interview Allergy test Spirometry: 20-24 years only Electrocardiogram: 25-74 years only Chest and neck X-rays: 25-74 years only Back X-ray: 25—74 years for men; 50-74 years for women Glucose tolerance test 33 Appendix II. Blood and urine assessments by specimen types and age groups .0E20> 3.380030 000:. .0 5.030039 .59050E09 4:300 000.9 03.09.00 35.0090 5.2. 3.9.08 035 :0 >.:0 00E.0~.00N .m0.00 0:9 0303.0 5.; 3.053 035 :0 >.c0 00E.0t00 03390390 05.9..0 0cm FOOw .c.9:....m_. . . 30.0030 30.0030 . . . . >555 0.0.000m . . . . . . . . . >000m0.u=2 . . . . . . 90:52. .0. m.00> vmém .605 .0. 23> OYON ”3.....0c00 >.co 23> ovém ”009.5:00 009..0:00 . . . . . . 55.93572 55.93.22 53.03.22 2..0 23> 3-0 H55:22.2 . . wZED O 5535 U :.Emu.> 0 59.95 0 59.9.) . . 2020:... .30....N 0:0 .... ~.o «0 000. E05 ms 02.0.0.0“ 0303.0 . . . . . c.E:9.< 55:92 55:92 c.E:9.< . . 05N n.5N 05N 05N . . .00000 .00000 .00000 .00000 . <5ES.> I «EN «EN Npmn NFmN N—mw 020.0“.N 03.0”.N 05.0“.N 20.0”.N 090.0“.N 3.00000 05059 90.. .80... :0.. m 20.6 05530.0 505.000.. 3.2.00 9m... 00..0u>.a...r 3.83.9.0 55:0“.N 5.00000 m5059 :0... .maoh :0: 5.296 05530.0 305me0 :0 ”30. .500 3.003.090 >.co m.m0> Emmm 60.00 0.5 55:0“.N 3.00000 m5059 00.. .50... 00.. 2.296 05530.0 305603 003953-003 ”30.0030 fistula EDm—ww 3.00000 95059 :05 .90... :0: 5:..00N 3.00000 @5059 :05 .20... 90.. 03.00 :00 000.9 00mm 5.>:0.0090.0 305me0 003953.33 ”c.90.0050;>x09.00 3059.03 00.09E::.000 "000.. 05.0» :00 000.9 00mm 5.>90.0090.0 30550.8 00.099.35.33 ”5906050938950 305503 00.35::000 ”000.. 000.0. =00 000.9 00mm 5.>90.000uo.0 305503 00.09E::.cw>0 ”c.90.m0E09>x09.mo 305503 003952.000 ”000.. 000.5 WAC—ts 03.0» =00 000.9 00mm 5.2350990 3059.03 00.090.30.903 ”c.90.00509>x09.00 23> p Th .0 3059.03 00.09.539.000 .m.00> Wm 00 305me0 :0 ”000.. 000.00 :00 000.9 00mm 5.2.0.00990 mwwEmew 2m ”Unwi— «0305 .3. 00:30.0. 03053 9.00». VNéN 236.0 “ES 0.3. Es. E 9w 22: m. .0. E00: :5. ”.00; N 0. 20:05 m m Appendix III. Pesticide residue and metabolite determinations Serum Hexachlorobenzene trans Nonachlor DDT and Associated Analogs alpha-BHC gamma-BHC beta-BHC delta-BHC Aldrin Dieldrin Endrin Heptachlor Heptachlor Epoxide Oxychlordane Mirex Urine alpha Monocarboxylic acid Dicarboxylic acid 3,5,6-Tn‘chloro-2-pyridinol Isopropoxyphenol Carbofuranphenol 3-Ketocarbofuran Dicamba 2,4—D Pentachlorophenol para-Nitrophenol alpha-Naphthol DMTP DETP DMDTP DEDTP DMP DEP 2,4,5-T Silvex 2,4,5-Trichlorophenol Appendix IV. National Center for Health Statistics and Center for Disease Control staff involved in the planning, development, and operation of NHANES ll National Center for Health Statistics Division of Health Examination Statistics Robert S. Murphy, Chief, Survey Planning and Development Branch James Scanlon , Everette M. Collins Evelyn Stanton Dorothy Blodgett Dale Hitchcock Mary Margret Wilson Connie Dresser Arnold Engel Helen Barbano Statistical Methods Staff E. Earl Bryant, Chief James T. Massey, Mathematical Statistician Division of Operations Headquarters Staff Henry Miller, Branch Chief, Health Examination Field Operations Branch Philip Howley, Operations Manager Thomas Makepeace, Assistant Operations Manager David Larson, Biomedical Engineer Jean Findlay, Survey Statistician Paula Wallace, Statistical Clerk Hilda Davis, Management Technician Judy Gray, Management Assistant Robert Benson, Clerical Assistant Kenneth McDowell, Supervisory Health Technician Brenda Lewis, Supervisory Medical Technologist Penny Allen, Management Assistant Charles Gallese, Operations Manager .Field Staff Joseph Campagna, Field Operations Manager Christine File, Field Operations Manager John Aldrich, Field Operations Manager Jay Anderson, Field Operations Manager Jerry Coffman, Field Operations Manager Althea Engle, Field Operations Manager Eileen Kennedy, Field Operations Manager Denis Hill, Field Operations Manager Margaret Kelly, Field Management Assistant Charlene Morton, Field Management Assistant Anita Allen, Field Management Assistant Holly Ferazzi, Field Management Assistant Gary Warren, Field Management Assistant Janet Warren, Field Management Assistant Marie Abbott, Health Examination Representative Dorothy Briggs, Health Examination Representative Mary Colbert, Health Examination Representative Laurel McDowell, Health Examination Representative Martha Peters, Health Examination Representative Linda Fant, Health Examination Representative Barbara Greene, Health Examination Representative Alfonso Small, Health Examination Representative Paul Terr, Health Examination Representative Doris Thompson, Health Examination Representative Linda Day, Health Examination Representative Alma Eubank, Health Examination Representative Patricia Warchol, Health Examination Representative Esther Allen, Field Operations Assistant Carolyn Petty, Field Operations Assistant Elizabeth Hill, Dietary Coordinator Janet Williams, Dietary Coordinator Ruth Griles, Dietary Coordinator Lorraine McCullen, Dietary Coordinator Lori Hornfeck, Dietary Interviewer Marie Mitchell, Dietary Interviewer Connie Foster, Dietary Interviewer Rebecca Wilson, Dietary Interviewer Dollie Kendrick, Laboratory Technician James McGuffey, Laboratory Technician Patricia Dowling, Laboratory Technician Ronette Hunt, Laboratory Technician William Johnston, Laboratory Technician Wilda Andress, Nurse Judy McKnight, Nurse Kevin Aubin, Health Technician Roberta Brady, Health Technician 41 Vondell Clark, Health Technician Charles Johnston, Health Technician Charlotte Leahy, Health Technician David Edwards, Health Technician Men's Emery, Health Technician Jane Robinson, Health Technician Jerome Waite, Health Technician Richard Driessel, Physician William Dodd, Physician Harold Holleran, Physician Lindsey Kirkham, Physician Verla McAnelly, Physician John Shirey, Physician Robert Wildt, Physician NOTE: This appendix shows the organization and staff as of the time of the survey. 42 Center for Disease Control David Bayse, Director, Clinical Chemistry Division Jane Neese, Chief, Nutritional Biochemistry Branch Richard Carter, Chief, Nutritional Biochemistry Re- search and Reference Section Wayman Turner, Chief, Nutritional Biochemistry Technical Services Section Elaine Gunter, Supervisory Medical Technologist Onno van Assendelft, Chief, General Hematology Branch Cornelia R. McGrath, NHANES Hematological Coordinator Appendix V. Data collection forms for NHANES ll NHANES Household Questionnaire Pom- Awmfi: 031.3. No. “-RISOI vow "Ii-3° DECK 37| none! - All Inlml-n mm. mu mu mmmuuun -! um indlvmnl will a. held In mm "°"'"’ cum-m. um u an only 5, pawn ova-pa In ma cu m puma! ol mo adv-1. no will no: u u "n alulou‘ or nun-I u emu: In: my Damn. ua. pun-.1: nun». llnvlcl I s‘ d 2 Id ' ‘ I C I w C W! ‘ O! u h“ ) . m . uni in! on . onuo mm In . n on. I NWSEHOLD WESTIONNAIRE n “In, ad- USE HEALTH AND NUTRITION ‘ EXAMINATION SURVEY I! .——. 0 __ 5-. m In your and damn (Includ: Hana No" Apt. N... 0! sum identification Lmln; “- Nonlnuwlw "In" and ZIP code) Sh“! TYPE A C] Mm - m In no. ”ST“ [:1 Nu m a u.- - menu an: Eta-:5” ' —“ [:1 Tmily dun: - Mm- M CRY : Sm- I ZIP code UM D on." __ w”! 13-15. a. m : : No. b. I; til: my ulll “In“! {:1 SIM u 5: Mn bu o! sud II dlll-r-M. (lncIudc ZIP code) T": I C] v-um — mmml [:1 Vlclnl - sum-I (Sill luau a—c, D Ulull mud-m mun-n “'7‘“ City Sou ZIP m. D Ann-d Focus a! 13-!” [:1 om. — your“ c. Spuiul pllu nun: Staph uni! mow Ty“ nod. TY?! C I M I 6. YEAR BUILT B:“"”:':: "u“ m“ (3 9° "07 A“ (7) DH"... mu "all: [:1 Ask - M «I m- nmm ulgmlly um! [I mm. mm . 5w' .1 . . I D Sucre 44-70 (Conclave mnmlw) D “I" I". M" I ",9 Mar 44-70 (Go lo It, cmlcu I'm-16nd. _ ' C] and Ind interview) D 0"" WW 7. Type ol living «mus .__¢ 1 3 Hull": unit a [3 OTHER unil —————-——— I. An- lelmtnts ONLY ‘5. Rama 0! all! C] I. An "an ally occuplod u "an «cum M Tlm bull" you own In 1M0 hull-1T E] Vu (Fill Tablt X) D No ' !!l “I“ E D b. An than any oecnlod o1 vac-1 IIvI-g gun-n I... Luldu your on on Iii- "all :1 Yu (Fill Tabla X) [I No I ”I: C] h In m my uh: hlldln an IMO pm in '00". to II" In - 0M" newlod u "an" a v“ (Fm Tabla x) C] u. u... .4... E] 1. None 2 DJIL pun. I‘M. LII. G. n ma 2, gut-flan ll. 3 pan. pal. 9. Land use ”I. m. u [j URBAN (11) 4 m. M. Raul-r uniu cocoa 02 a! B4 in ilom 1. z [’1 RURAL (I0) Spaci-I place units coded 32 o: It in “a. " .m 2 mo coded 85-98 in am 5:. 5 9.... “a. un. IO. Do you at a mu Oil: place! [:1 Own D Mm E) Run for In. 6 ”no “a. "I. Don IM- pluo you ("Mum/nu! luv 0m) haw ‘0 lens ‘6. Lin lint numb.“ cl sumo" WM“ 0: no"? I D Yu 2 D No (Ila run-lain; to bc lnurvlmd. 5. During vh- put 12 unfil- lld ulu IT can, llvuml, and CI "“3 «ho: lu— ”dun In. M- pl-n man to 850 u an? 1:: Va (III 2 a No (I?) “n. "w” :. During Ilia you ‘2 much III “I” .l :N'I, Iivunek, and «In: Sun pain" In. Nil- plan now" to 3250 u .01., I D Yes a D No I I 13. VIM I: oh- v-lnphm muhv hut? D Noun lh. For "Iin Type A noninwvluwl. mm nmu. Tclufiono ‘ nus. And In ol houuhnld mun. For nlusal households. circIo lino N" M. "wk" number of person who refuses. Nun ' In. Au 50: Ill. Innrviewcv's nlm. Cede ' / 1 Mom 3 4 5 6 b. I!» null-l lllls lulu—Ill"! Nun- Numtm m1 mm. ram. 91 be! mambo! Cily causus 33.35.?" 13.33373: USE WLY In. Uh! I: rho gene of the he“ .4 rim household! Enter name on firlt line. I. What In the rue-es .r I" M per-oat who live here! List all persons who live here‘ Be sure to list all persons in the correct orfler. e. I but lined (Read mules). II there uym eln Ireyl-g hr- nevr, "eh u Moth, "hunt. or rec-en? D D d. flue I allied one!» I'll. USUALLY llvu here but l| m away he. had. . . ............... D D e. De “7 d the mle In M- Lou-eh“ ha I hone Inyvrhn nlu? .......................... D D ' Apply mmw mine-rump lulu. I. Are any of M‘enue la III: hunch“ u- " Gull-ol— nrln {My wl Che Arr-ed Fore“ of the United Stern! ‘‘‘‘‘ D Yes——¢ Linen) _ (Delete) D No Howl -- khan-- nun.“- . _ ' V _ (w'u .43....) .11-". 5am" 14::ng Name (First. muddle :muul. In!) U}: card to check ELIGIBLE term Circle line number of ”m" 4'"? ""4 an Circle SF': nwmald respondent ’°' ‘°"""""Y 1.. h. 2:. 2d. ‘ u. ‘ w 3" mama... m... 0., y... M. s v..' 9r v.. u 9.. l 2 3 4 5 6 7 I 9 l0 SAMPLE PERSON SELECTION PERSONS PERSONS PERSONS 6 mm — 5 years 6 years — 59 years 60 years - 74 years lst. 2nd. 3rd. 5th. 6th, 7th lst. 5th. 9th 15:. 2nd. 3rd. 5th. 6th. 7th Ind. 3rd, 4th. 6th. 7th. 8th 2nd, 661, loan 2nd. 3rd, 4th. 6th. 7th. 8th In. 3rd. 4th. 5th. 7th. 8th 3rd. 7th, Hm Isl. 3rd. 4th, 5th. 7th, am In. 1nd. 4m. 5th. 6th. Brh 4th. 8th, IIth lst. 2nd, 4th, 5th, 6m, 8m ~ D No 5-an- PersoMs) — Elploin to respondent why no [antler CHECK ITEM A question. Gotoponhitem 13. D Sample Perm-(s) ~ Fill Medical History Note: FOR ARMED FORCES HEAD OF FWLV. "LL ITEMS 1-, MY W 60 TO PAGE 4. LInI nun" (Tnnurlh Iron our 2) (HEAD OF FAMILY) 1. Dmnlhinhflmnwlbohwupl) m b °" b m‘ 3. Ag. (Trot-“mu Iron pan 2) 3. I m l@ v.7. 4. Su 4. l um- I D smu- 5.’ RI“ 5. u D mu 1 a Slut I D on. 6. ha whet 89m um -- Ion? Emu ma non: of IM Sum or Ioni'n many. Sun or lowly! «mm 7. In —- «I married. VIII-Id. div-red. III-Mod. Ir nut and.“ M one he: 1. u D on“: n 4 [j nan-nu x D mum : D Scum-Id n D mama s D un- urn-d PIIIII look I. MI «Id. ("and cm 0) C. “III III I! Mu gm” IIS‘I‘ hurlbu --'I nun-II origin or sunny? I. Emupm I! an“ 6 yous. mull "Nona." " halo" ('0) 9:. “I. in Oh. Mi." .N‘t II you of tog-hr "bl -- III M M 69 @9 ®0@® s. an -- mm .5. -- ”a. (yum ASK IF I70; OTHERWISE GO To NEXT SP 0R QUESTION H PAGE 6. "1th vu -- III” “031' 04 lb. pun l! “I, (For all") MI. or dub. Mk. III-T (For 'I-IIII) Km way-m... or III" I. I II b. __________________________________ 4 I D Wuklnfl (10d) 1 D Kminl nous- (10¢! a U Son-mm u I D Layer! 2 U ln‘u-d I D Sludlnl A a [II I D Saran. m u n Lama. “! m 1 a Union a nun o a Door — Melly - --—< c. Old -- work It I lab at Lulu-I AT MY TIMI bring .- pm “III! “I, .. I an: 1 D No my; I. “II -- "I "than. did it uully nut fill ”It It pun “In? I. 'a Full an x a Puni- "I. D“ -- workday “II II" In! I'M-uh hinnmmmln-uiumfihhun! HI. I! luv" (12; same 5. Ivan though -- did at work krlu ‘0' flu. in: in how I [It or bud-on? h. I! I D Yu 2 D No a. 'II it look 9 hr wall or to by.“ h.- I Id? I. m i D Y" 1D No (12) thlch-lufii-‘Mnduulmflhclofl a. lDLookml : 0 Lara" a D Beth A“ {of I" III. For when Ill -- wort? Noun 0! My. busineu, maxim, or u“ E”"’" ""9?in n on"! employ" ”YE. "my. 5. M H“ II hula" Ir inhnry II MI, For "any“. TV and Min I. "““"'Y in He only. manuluum'ng. mail If!!! sum. Sum LoberDm. fun- In “““i‘m‘ '1‘ c. M land Il work no. -- doll" For "II-NI. chant-l angina, c. “WWW through IZI lwly stock clerk, lyplu. [m Esra?" ‘ HJTI-h-I; :l-l -- 'I out 1”! “Ohm" or Mm! For IIWI. I. 0mm "" (was. but account boon. lulu. ulll cm. mu printing mu. clvillnn ”.- Iinim: concrete Complcu horn Inuit: ln III-d: it not :Int. at: “I" M "b" I. 'II -- In I- d I FIIVAYI «nu-1.5.“...- Ir Hlvflul _ Mum'uhq,oru-III|IIY.. . ® ‘0' 'D' - I 'IDEIAL WWI . : - STAYIpv-mc-anL. .s ‘UF ‘USE -- I WM. ”mu-III Inlay-If ........... .L -- Idmw In "I bum-I, mu... "Iain, Ir Gnu-Y ' D s 7 0” lfnfll'mllk: hob-515?)?“ ..l ‘UL .DNEV 01hr.) ......... :l' -- walla. NITIIWT PAY I. “all; huh." Ir fur-f. --IIV!IIOIK-.. :IV 13.. and -- m. um I. in And rum .0 ch luv-d Smut u. @ .g m g a u. 04le” era. 1:; Wm En Mu. '64—Awl '15). . . .vu 3 w L. In... m u. um? '- UW so—J-u 55.). m u. :2: . C! as" M box in «standing order 9! priority. 'M‘ V" II (5.1-. 0-]"7. "7) ' U Tim it man served in Vietnam and in '0'“ '3' ' (Mill ”4‘" II) 3 U mm . U DI Kern. mark VN. Pou Vim-I (M '75 wu- 00w SIM“ (all «M! 9:53!) . . . . OS GO 70 NEXT SP 0* QUESTION ’4, PAGE 6. 4s Item Line number (Transcribe Irom page Zl .N Date 04 birth (Transzrlbe from page 2) 3. Age lenszn’be Irom page 2) z D Flmlle 5. Race 5. CD 4. Sex a. iDM-l. x D Omar Sme or human country 6 In what 300M nu —— born? Enier the name of the Store or lorelpr country. ‘- 1. Is -- "w married, widowed, divorced, "pound, or never married? Mark one box 7. I Dung. I7 IDDIVDIC“ z D mrma s D Marina 5 g wiaowed e D Never run-u Plea" Ink II "III curd. (Hand Card 0) 'I IEST describe: --'s national origin oi lnGII'ly? I. Errm pronoun II under 6 years. mark "None." 9-. o D None (IO) ’1. Who Is It. high-II grade or year .5 reguIer uhul -- he: ever attended? 2 D Elem ..... s D Hugh . l 0 College . 5. ma —_ line-I. ll.- -— .r-d. (year)? s. . D m z D No ASK IF I70 OTHERWISE GO TO NEXT SP 0R QUESTION I4, PAGE 6. 10.. Vllm w“ -— m... MOST .l lli. mi 12 unfln? (For males) Wading u doing samnhing .Iu? 10-. i8 mm... (you; (For Icmales) Keeping lieu", working, er dallw 2 K-eniu houu ”Del Imrhing else? 3 D Superman I - I D Layoff : D Reured 1 0 Sudan: 4 D III 5 D Saying Mm- sD Lookiru IM work 7 D Unable i. work d. In... - wu "in... did In usually work full u... .r pan m... a, i :1 Full um. 2D w... u... Iiu. 20 lav-um rune Ii. @ __i [:1 Yu 3 D No III. Dld -- work a! any time II" weak or the Hull before not counllng walk around the has L [nu ma -- d not work ‘U'ifl' III-0 Ila-a, has In luv :- rm Ii. Inklng for mi .r u. lay.“ I... . loin .. 39 .D m , El N. m, I. VIIIeII — lukln’ for work or on layo“ Iran I ioi? d. I D kainl a D Lava" s D gain Ask Ior all 12-. For when did -- Ivuk? Name of company. business. organization. or 12.. Ew'wu persons with a other employer My: "'fiufif” Ii. In... kind .l huinan 01 Industry iii-El ”secular: TV and radio . in I I: only. cautions 12- e. Vlm klnd of work we: — doing? For clamp e, e ecmca engineer, e. O‘WWIM mrough III apply stock clerk, typisz, farmer “Am? ”a.” I a In“ lap."- ml u I? For example. I. Dun" L_ _5 “WW“ types. keeps accouni books, files sells cars, operates primrn; press. “V""l‘ l°"- ._-.fl'y§'1=_s_c9:vc.rsr_e _______ Complete Irom entries in 12- . i! Mi clear. ask. a. VI n elplrylc of I PRIVATE company, hliuaa, 0t indivi‘ual 0. hr wa‘n, salary, or GOIIIII Ion’ ................ F 'D P 'D' 1 D F I U SE —— “II-employed in own mum, pl 3 El S 7E! W II no: I Ium, ask: I: who Muir-us Incorporated? Yes ..... . . ‘ D '- ' D "EV -— working WITHOUT PAY in family. business or Inn? —- NEVER WORKED lac. Did -- our 1 e in llie Arm-d Fore-s II III- Un ed Sm“? 11.. I 0 Von 2am: (NIIISP NO. 14; 5- W J" h ? Vietnam Era (Aug. '64—Aplil ‘75). . . . VN b. In“ I . u". Korean War (June 'SO-Jan.'55) ...... KW '0 v" 'D W” Mark but in 4 mm; wier er D'Iorlly, World War II (Sept. 'w-July '47) . . WWII 2D Kw egos Thus .1 perv“ . .neq a helnqm and m WW” “I! I (Aw-l 'I7—N0v. 'IB) .WI .gwwn ID on Koren. mar» m. Post Vietnam (May '75 In preset: . . . PVN "I Other service (Ill other periods) ..... OS ‘0 GO TO NEXT SP OR QUESTION ll, PAGE 6. MY (all I c%f l 1—”— 5 Dly val Mum!“ V0"! lo eaeeea e uljlmle ‘D Me A. lf:;ml‘ z I; | Fomme z ['1 Fulllle 2 U Fem-lo 5. 'i lwmle 5. I L] mm. s. I :‘j Mme 11f] sleek : 1;] Black 2 [1 Black 3[: 1cm. 3 ['1 Omar : :3 on... 6. 5m. 01 lmlgn «may 6. Sun or lonely. counuy 6. 5m: a lamp century 7 . r | um“ n 4 D Dlvnleod 7. (on) ' Under [7 'Cl Dlvovctd 7. l Q umu I7 I [3 Dime-a 2 L: ‘ Hanna 5 [j Sop-mud Hanna 5 C) Sop-med z [j erlied ! [:3 Sultana : [:1 wmowea I 1:] Never mlmcd ‘_ Wldowed u D New: man-ed a {l VII-dome 4 C] NIVII mun-d l I- a Euro: pncoda |~ . Euler mood- h. 9.. Noni no; 'u- o [3 None m» 2 J 4 s e 7 s Elem 2 3 4 s s 7 a 1E]Elm ..... l s e 7 a afimgh. l 2 3 4 sum"... 1 2 4 ' aim-nu... A L'j Coll" . l 1 3 4 s» 4 [j] Cell." 2 3 4 s. 4 [3 College 5‘ 2 L 1 No . umwmm; (we) 2 C3 Km.“ house (10c) : [1] Rennd : m Sludenl l D [II s [15mm home s L] Lookm: lo: walk 1 L' ] Unable lo «all u [1 on... _ Sanity 1 Lil m m») I C} Llyoll : D Rom“ 3 [:1 Sud-u l D Ill " Wovkm] 110d) lumping housa "Dc; [:1 Sam-mm; else 5 [j Sllyln‘ home 4 [j Lookmg lnr work 1 D Unlbll lo work a [:1 04w — sucuy .. IDWnrklnl 110a; z[:1Kc-pmg um. (10:) a L‘] Sammy"; I|u {my a C] Rnilcd s E] Student - D [II 5 E] Snyiu ham. 4 C] Looking lot walk 1 CI Unable to wor‘k u [‘1 Olhu - Smlly I [:‘l Full lune 2 B Pm mn- lava ID Look-n. .. IDkamg ID Yu (12} 2:] No , [IL-1°" 2 C} L-yw : C] son. a C1 am m. Empleyu l2. Employev m. Ewlayu ' ‘ i ‘ ‘ ' " ' ' Elia—fit; """""" Elan—57:7 __________________ ‘ 1." _____ mafifi; """"""""""""""" ’ " 02ml“; _ -Oc_ z D Food st-nos null-Ne (23) 1. | E] No woven aveillhle (09. PI) 13'. he yu unlfle‘ I. unkiuh in the led I'll, mill? c. What (I the IAIN new you Im't pnlelntin in the mun? :gzr h I a Yes. regularly : D Yes. ocnsionefly : No } "a. IUNoneed 2 D Not enough money It the tune 3 D No lvllspolulion A D Pude s D Other - Speedy Notes 3...: 4...: 0.9:: .1533 .0. £038.... 02.....3 5 «:5 on zo_.—. 2 0.9.6 v.3 a: no» 35.5.8 E253 0.550 U 4 m n 92 a. 2 on I uu> ._.o :1 2 oz nu> 02 an) 2 SEC ‘5 92 no» .3252. 20.5: 3.350 .IIJI. 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I :5 six...» . .o: I .. 9.95.55 4.3 021306 22-... 2283 .2. a. n «I.» 3: 3.5 5.1.5.. $2.3. .52.... 3.1. u... 2...... 28:32 593-. $8.! :3 in... $553 I... v..- 3!... aulg< nub“... h< ale—kgiuuhha «GP—ii; $2.24 I x nan!— 25: 2.... _ .35.... .023 hwwzm 0.:th T|>K§L .3 vii... :5. hmci 3. .85 33 529.63 ; 2C] Under |8 (I4) l3a. Have you smoked at least loo cigarettes during l your entire lite? :. l D Yes . 2 D No (13h) b. Do you smoke cigarettes now? 1., El Yes ; 2 1:] No (13d) . On the average, how many a day do you smoke? . How long has it been since you smoked cigarettes fairly regularly? @6 Cigarettes per day (13¢) Years (IS!) 77 C] Under l year 93 D Never smoked cigarettes regularly (IJh) SSDDK . 0n the average, how many cigarettes a day were you smoking l2 months ago? (9 Cigarettes per day as C] Did not smoke 99DDK . During the period when you were smoking the Cigarettes per day . About how many cigars a day do you smoke? 6 I most, about how many cigarettes a day did you l® —— usually smoke? : 99 l: DK . About how old were you when you tirst started : smoking cigarettes fairly regularly? '. Years old ’ ‘ : 98 D Never smoked regularly : 59 C] DK . k - ? ' Do you smo e cigars now :@ 1 D Yes 1‘ 2 C] No U31") i Cigars per day k—(lF LESS THAN 1 PER DAY) 93 D 3 to 6 per week 99 D Less than 3 per week h. a Do you smoke a pipe now? ® 1C1Yes 2["_‘|No (l4) About how many pipetuls of tobacco a day do you usually smoke? 6 Pipefuls’ per day rlIF LESS THAN l PER DAY) 77 C] 3 to 6 per week 98 1:] Less than 3 per week ’l4a. Do you drink coffee? . On the average, how many cups or glasses a day do you drink? '2. 9 1DYes 2 D No (I48) Cups or glasses 0 |:] Less than one per day . Do you usually drink decaffeinated coffee or regular coffee? ® t E] Decaffeinated 2 C] Regular 3 C] Both d. Were you EVER advised by a doctor to use decaffeinated coffee? (For example, Brim. @ l D Yes Decaf, or Sanka) 2 D No e. Have you EVER been advised by a doctor to stop drinking regular coffee? @ l D Yes 2 C] No 150. Do you drink tea? ‘D Yes 2 C] No (l5c) . On the average, how many cups or glasses a day do you drink? @ Cups or glasses 0 [:1 Less than one per day | | c. Have you EVER been advised by a doctor to stop l drinking tea? I. l D Yes I 2 C] No 16a. During the past 6 months, did you use any aspirin ‘ or aspirin-type pills? I@ 1 D Yes 1 2 [:1 No (I7) I b. On the average, do you use these pills one or more x times per week? I. l D Yes 2 E] No _>—_. 17. In things you do for RECREATION, for example, sports, hiking, dancing, and so forth, do you get much exercise, moderate exercise, or little or no exercise? I [3 Much exercise 2 [3 Moderate exercise 3 D Little or no exercise 18. In your usual day, ASIDE FROM RECREATION, are you physically very active, moderately active, or quite inactive? 6 t E] Very active 2 D Moderately active 3 D Quite inactive 19a. 5. What is the most that you have ever weighed? (Do not include the times you were pregnant.) 9 Pounds How old were you then? 9 Years old Notes 73 '3» 74 CHECK ITEM B > E. [j l8+ (20) l 2 D Under l8 (Check Item D) 20a. What is the least you have weighed since you were IS? I). Pounds 50 How old were you then? I l '. Years old CHECK ITEM c > '. IE] 2.5+ (2i) : 2 D Under 25 (Check Item D) 21. About how much did you weigh when you Were 25? l E. Pounds CHECK ITEM D > ll. 1D l7+ (220) : 2 [:1 Under I7 (23) 220. How many living children do you have? :. Children I o E) None CHECK ITEM E > :.1D Male (23) l 2 B Female (22b) 22b. How many children have you EVER had? l I ' d :@ _ChI| ren I 0 [3 None (23) . How many at these children weighed 9 or more pounds at birth? E 252 Children l 0 [3 None 23a. About how tall are you without shoes? . About how much do you weigh without clothes or shoes? é® Feet :. Inches I :@ Pounds 24a. During the past 6 months, have you lost any weight without trying to? . About how much weight have you lost? l@ _Pounds 25a. print WITH GLASSES with your - Lelt eye? ............................. Right eye? ............................. . Was your eye condition the result of an accident? Do you have any reason to think that you ' I Yes are color blind? E. 2 g No l 9 1:] DK I . Have you ever had a test to see whether I I Yes you are color blind? :. 2 g No : 9 [:l DK . Do you have SERIOUS trouble seeing with one or l I D Yes both eyes EVEN WHEN WEARING GLASSES? :. 2 D No (26) J . Can you see well enough to read ordinary newspaper l Yes No I E.t|:| 2|:| l.'|:l 21:I :@ IDYES : 2|:|No DIABETES 26a. Do you have diabetes or sugar diabetes? @ 1 CI Yes 2 Cl No (27) b. Did a doctor tell you that you had it? : 1 Yes :. Cl : 2 D No 27a. How many livirég brothers and sistebrs do you hgve? I: Do not count a opted, step or ha i rothers an sisters. L‘vin ;. —— ' g I o [:1 None (27c) l b. How many of these brothers and sisters have : diabetes or sugar diabetes? .@ Diabetics I I: o D None . How many oi your brothers and sisters are : not living? :. Not living 0 El None (27a) "3;K.T:::::J:::zi:'zzt:;:°"“ W“ No E o D None e. Including those living and deceased, how many oi 1: your brothers and sisters were born before you? :. Number : o 1:] None l. Is your mother still living? E® ‘l:l Yes E 2 D No 9. Does (did) she have diabetes or sugar diabetes? l@ ‘ Cl Yes E 2 [:| No h. Is your lather still living? E@ ‘lj Yes : 2 [:| No i. Does (did) he have diabetes or sugar diabetes? 43. ‘ I: Yes : 2 E] No 28. Have you EVER been told by a doctor that you have - Yes No Borderline diabetes? ....................... @ 1 [:I 2 [:l Prediabetes? ............................ I. ‘ D 2 Cl Potential diabetes? ........................ ' @ ‘ El z D Notes i. 5 75 CHECK ITEM F > i. 1:] "No" in 263 and all of 28 (Check Item 6) i 2 [:3 All other (29) 29a. About how old were you when the doctor tirst told you that you had (diabetes/.. :. Years old . Weve you a patient in a hospital at the time a doctor first told you that you had it? E.‘ [:]Yes 2 [3 No (30) c. Were you in the hospital at that time because you had l® Y symptoms of (diabetes/. . .)’ i. ‘ [:1 es . 2 [:J No 30. (Not counting that first time) Have you ever been i Y hospitalized because of your (diabetes/.. : 284 ‘ [3 es I 2 [3 No 1 31a. Have you EVER taken insulin injections? {.1 El Yes I : z [:1 No (33) i b. Have you been taking insulin injections ior most oi l , Y s the past 12 months? :. 2 g N: c. Are you NOW taking insulin infections? 1 C] Yes 2 C} No d. How )many years (have you been takingfdid you I take) them. ' Y :. ears I o C] Less than | year 32o. Do you know what an insulin reaction is? I. 1 [3 Yes 2 C] No (33) b. Have you EVER had an insulin reaction? {@13 Yes i 2 g No (33) c. How many insulin reactions have you had i during the past 30 days? :. Number I : o C] None d. (Including these reactions) About how many have i you had during the past l2 months? :@ Number l 0 [1 None I 33a. Have you EVER taken diabetes pills? i. ‘ D Yes : 2 S No (34) b. Have you taken them most of the past ‘2 months? E. 1 Cl Yes 2 {:1 No . What is the name oi the medicine? — SpeCify . Are you NOW taking diabetes pills? I I 5.1:]Yes I K . How )many years (have you been taking/did you to he) them I E. Years : o :1 Less than | year 34a. Have you EVER been given a WRITTEN diet for o [:1 Less than | year your (diabetes/ . . .l? l. l D Yes I“ 2 D No (35) + b. Was this diet ordered by a doctor? ;@ ‘ D Yes : 2 D No 1 . . , r c. Do you NOW lollow this diet. :. ll: Yes l 2 E] No v d. How many years (have you been were you) on l o diet (or your (diabetes/ . . .)? I Years | x 35. Do you carry or wear an thing which identities l you as a (diabetic/ . . 3? :.1l:l Yes ; 2 C] No 36. When did you lost se/e or talk to a doctor : b t d' b t . . . ? u on your( Io e es ) E. Days 5. Weeks l E. Months 3. Years 370. During the past 12 months did your (diabetes/ . . .) T. ‘ I: Yes cause you to cut down on the things you usually do? 2 E] No (Check Item 6) b. During the past 12 months, about how many days did you cut down on your activity for all or most of the day? __.___‘Days 0 D None (Check ltem G) c. During the past 12 months, about how many days did this condition keep you from work or Days school, not counting work around the house? 0 |:] None d. During the past 12 months, about how many J days did your condition limit the kind or amount \. Days of work around the house you could do? ‘ 1 o C] None e. During the past 12 months, about how many l days has this condition kept you in bed all or 1. Days most of the day? t r 0 |:] None l l l 1 Under 25 (38) c H E c K | T E M G J D r 2 El 25+ (43) l Notes 77 78 RESPIRATORY CONDITIONS 38a. Do you have trouble with recurring persistent i® 1 [:1 Yes cough attacks? : 2 D No (39) 1 b. Have you been bothered by such coughing attacks :69 1 I: Yes during the past 12 months? i 2 i: No l 39. During the past 3 years have you had a period of ‘ Yes increased cough and phlegm lasting for 3 weeks i. l D ' or more? : 2 D No I 40a. Have you EVER seen a doctor about a lung or I 1 D Yes In - . ? '@ c est condition : 2 D No (43) b. What did he say the condition or conditions affecting your lung or chest were? c. How old were you when you first had i V the condition? . , I: Under [0 _ Specify l 2 |:] lO—l9 years old l l 3 [:1 20—24 years old 4]. About how many work or school days have you lost I during the past 12 months because of your lung 1. l [:l Tlone condition, not counting colds or the "flu?" I 2 D _4 days i 3 C] 5—9 days l 4 D l0—I4 days i 5 D |5—l9 days i a El 20—29 days j 7 D 30 days or more 42. Have you EVER stayed in a hospital overnight ‘ Yes or longer because of a lung or chest condition? l. l l: l 2 [:i No I HEARING and SPEECH } 43a. During the past 12 months, have you EVER been l@ 1 C] Yes bothered by ringing or other funny noises in ; ? 4 your ears 3 2 D No (4 ) b. How often — every few days or less often? l@ 1 I:l Every few days : 2 |"_'| Less often c. When it does occur, does it bother you quite a E@ l E] Quite a bit bit, iust a little, or not at all? i 2 a Just a little E 3 C] Not at all 44o. Have you EVER had a running ear or any discharge l. 1 [3 Yes from your ears not counting wax in the ears? : 2 I: No (45) : 9:; OK} | b. How often have you had a running ear or any discharge ! from your ear? '@ l g gnce only ' 2 che 3 G 3—5 times c. Did you see u doctor because of this condition? 9|:lDK 1DYes 02D,“ 9|:|DK 4 D 6 or more times 45a. Did a doctor EVER tell you that you had an ear infection? 1 C] Yes 2 a No (46) b. How many times have you had an ear infection? c. For how many separate infections did a doctor prescribe any - Oral medication (pills or liqm‘d medicine)? .......... Shots or iniections? ......................... Eardrops or other external applications? ........... d. Did a doctor EVER treat an ear infection you _______ Times I. __ Infections l I. __ lnfections .619 :@ __ Infections c. How old were you when you first began having trouble hearing? had by placing tubes in your ear? E 332 I C] Yes l l 2 D No I g 9 :1 DK 46o. Have you EVER had deafness or trouble hearing with ‘ one or both ears? Do not include any problems which l 1 El Yes lasted just a short period of time such as during a cold. : V I 2 [:1 No (461) l b. D'd EVER d t b t 't? ' i you seeo ocora ou I :.1[:]Yes : 2 a No 'I@ ~ C] 0—4 years old I 2 [3 5—9 years old 3 [:1 lO--|9 years old A [3 20—29 years old 5 C} 30—39 years old 6 C] 40—49 years old d. Since this trouble began, has it gotton worse, gotten better, or stayed about the same. i E] Gotten worse 2 {:1 Gotten better 3 E] Stayed about the same 'e. Was your hearing trouble or deafness caused by - An ear infection? .......................... A loud noise such as that from machinery, gunfire, blasts, or explosions? ....................... Ear surgery? ............................. An eor iniury? ......... - .................... Were you born with it? ....................... Some other cause? - Specify __.__—_———- I E l l l I I | E l 7 E] 50 years old or older I I l l I I I I I I I I Yes No I E@l[:] 2:] l £00 25 I :O'D 2:1 i.va 2C] 3.15 am i®1g 2:] DK 9D 9[:l 9D_ 9D 9C! 9D 79 80 46. Continued 5. How would you rate your hearing in your RIGHT eor — good, lair, poor or ore you deal. I@ 1 (3 Good 2 a Fair 3 [3 Poor 4 E] Deaf 9. How would you rate your hearing in your LEFT ear — good, lair, poor or are you deal? @ 1E] Good 2 E] Fair 4 [j Deaf h. Have you EVER had an operation on your’eors? @ I[:]Yes I | | l l I I I I I l | | | | | | 3 [:1 Poor I I l l r I I | I | | | I 2 [:1 No (4bj) i. Was it - Yes No DK An incision of the eardrum? ................... :. ‘ E] 2 El 9 E] An opegg'tion o: the stapes, one of the bones in l the mi e ear. ........................... l :@ I [:1 2 I: 9 E] A mostoidectorny? ......................... :.1 [:1 2 [:l 9 C] Some other operation ? — Specify :.1 E] 2 Cl 9 E] j. Hove you EVER had your hearing tested? | | | l I :.1DYes : 2 [3 No (46m) R. How old were you when your hearing was LAST tested? | l , 0—9 1@ 1 :] years old 2 E] l0—l9 years old 3 I: 20—29 years old I. Was your hearing normal? @ iDYes ZDNO l l l i _ : a C] 30 years old or older I I i l 1 9 [3 DK m. Hove you EVER used a hearing oid? n. Which ear? :@ rDYes l 2 [:1 No (Check Item H) | 1 R‘ ht :@ D '8 2 I: Left 3 C] Both 0. Do you now use a hearing aid? :@ IDYes I zaNo CHECK ITEM H > :. 1E1 |7+ (47) : 2DUnderl7l5l) 47. Have you EVER worked at a job where the noise level required that you speak much louder than you usually do? 3@ iQYes : ZENO LIVER A'ND GALLBLADDER CONDITIONS I I I 48o. Has a doctor EVER told you that you I l D Yes had a liver or gallbladder condition? 5 2 Cl No (49) b. Did the doctor say the condition l c. Do you still have . . .? d. How many was any of the lollowing — : years ogo : did you first : have it? I i If “Yes,” ask 48c and d. : Yes No Yes No DK I I I Hepatitis? ......................... Cirrhosis? ......................... Inflammation of the gallbladder (Cholecvstitis)? Gallstones? ........................ Liver obcess? ...................... Hemochromatosis (Hevmoe-crow-ma-toe-sis)?. . . * 'X' ‘X- 1‘ @999699 ID 2D 3C] 4D 9:1 ‘Cl 2C! 3:1 «I: 9:1 ID 2|: 3:1 «I: 9C} ID 2:1 3E! 4:1 9E! 1:1 2D 3D 4D 9:1 ‘Cl 2C! i 3:1 4:1 9:1 (33999996 4D l0—l4 days 5 D 5—“? days 6 a 20—29 days 7 D 30 days or more I I I I I I I I I I I I I I I i I i * I Some other liver or gallbladder conditionv. . . . E * IE] 2 D 3 D A D 9 D Specify : e. Has a doctor EVER treated the liver : or gallbladder condition with — l Yes No I R I irh llbl dd ? .............. ' i 2 emova o e go o er E@ D B Any other surgery? .................... l. I D 2 D I M d‘ r' ? ........................ ' 2 e um Ion :63 I C] C] Diet? ............................ :. I [:1 2 D I a d ? .......................... ' e rest E@ I D 2 I: Some other way? — Specify :. I [:1 2 [:1 I i l. Have you EVER stayed in a hospital i overnight or longer tor a liver or :.1l:l Yes gallbladder problem? : 2 D No 9. Are you NOW being treated by a doctor ' for a liver or gallbladder condition? i.1 D Yes : 2 D No I h. About how many work or school days I have you lost during the past l2 months l. ‘ l:l None as a result of your liver or gallbladder : 2 [:1 |_4 days condition? : : 3 B 5—9 days I I I I I i I 1 81 82 49a . Have you EVER had trouble with persistent itching all over your body? :. IDYes i 2 C] No (50) I b. Was there a rash along with the itching? E® 1 D Yes I | 2 D No 1 50a. Have you EVER lost your appetite for a period lasting ' one month or longer? :.1 D Yes : 2 III No (51) ~ 7 i b. Do you have this problem now. i. ‘ I: Yes I 2 D No KIDNEY PROBLEMS } 5]. Have you EVER had any kidney,.bladder, or other :® 1 D Yes ' bl ? urinary pro ems : 2 Cl No (56) 52 . - ? ' 0 Have you EVER had ludney stones E. ‘D Yes : 2 D No (53) b. Have you EVER passed a stone? : :. 1 [I Yes i 2 E] No c. Have you EVER had any of the following kinds of l treatment for stones - : Yes No I Medicines? ............................... :. 1:] 2D ‘ . Surgery? ................................ :. ta 2‘: I Special diet? ............................. l. 1 El 2D I Any other treatment? — Specify ' I [:1 2 D E. l 53a. Have you EVER had any infections of the kidney : . 9 ' 1 D Yes bladder or urinary tract. :. 2 D No (54) I i I I I i I I I I I I I I . About how many times have you had an infection of the kidney, bladder or urinary tract? Times . About how many times did the infection(s) involve the - Kidney? ................................. Bladder? ................................ Urinary tract? ............................. 5. Times Times Times . Did you have fever and chills with any of the infections? . For how many of these infections did you take antibiotics or sulfa drugs? . For how many of the infections did you see o doctor? I tDYES l. ZDNO Infections o D None Infections (54b) I o D None 54a. Have you EVER seen a doctor for any : kidney, bladder, or other urinary problem? :. l D Yes : 2 D No (55’ 5. Was the doctor —- E Yes No I . . , A General Practitioner. ............. a. 1 C] 2 [3 An Internist? .................... l ‘I 2 [:1 I I A Urologist? ..................... 1 ID 2 C} l A Ne hrolo 'st? .................. ' I 2 P 9' :. E] D I Some other type? - Specify :. 1 [:1 2 C] I c. Did a doctor EVER tell you that you had — i d. Do you still have . . .? e. “our many I yewsqodid ' the condition l begin? I If "Yes," ask 54d and e. : Yes No Yes No DK l I . 't' N - -t' ? .............. I r. .— Nephnrs( efry Is) I..*1E] 2:] am am 9l_l Renal sclerosis? .................. :.* I [:I 2 E 3 E] 4 B 9 C] l I . . , . I Kidney stones or stones in the ureter.. . . . ?.* 1C} 2 :1 3 :1 4 9 C} Nephrosis (Ne-fro-sis)? ............. :@ 1D 2 a SI 4 D 9 S I * I Kidney abcess? .................. :.* 1 S 2 {:j 3 [:j 4I 9 D I Hydronephrosis? .................. : 1 [:I 2 C] 3 :1 a [:1 9 D I * (Males) Enlarged prostate? ........... I 2 [:1 3 :1 a. 9 a Bladder stones? .................. EI 99 9 E] ‘X' 2:] 3C} 4:] 9D Kidney infection? ................. .* I E 2 C] 3 C] 4 [:] 9 E Bl dd ' l ' ? ................. 2 3 A 9 a er In ectIon » .*1:] I E] [:1 E] Urinary tract infection? .............. . 1 l: 2 C] 3 C] A C} 9 D -)r Any other condition ot the kidney, bladder or urinary tract? SDeCifY ....... g 6 @9®®699®®99 2:} 3,_ CI 9 a "i l. About how many work or school days have you lost during the past 12 months because at your ‘ g None kidney, bladder, or urinary condition? 2 I_J l'4 days 3 f: 5-9 days 4 :1 l0—l4 days 5 C] l5—l9 days 6 C} 20—29 days 7 a 30 days or more 9. Have you EVER had any special X-rays of your bladder, kidney, or urinary tract? .—.._4 _____.-_.-_-____________——_-________.-A....- 1:]Yes I 23% 9 84 54. Continued b. Have you EVER been bospitalixed oven ni‘t or longer because of any trouble in your kidney, bladder, or urinary tract? '1 I @ IDYes I 1 2|:[No i. 'ben was lbe last tine you saw a doctor lur a kidney, bladder, or urinary condition? ‘@ o D Less than I year ago Years ago j. Did tbe truer-rm for a kidney, bladder, er urinary tract proble- inelade — Yes No Diuretics lDi-yr—ret—ic) or pills for Inter loss? .................. 1@ I D 2 D Steroids such as cortisone (cor-ti-zone) ' and prednisone (pred-ni~zone)? ..... . 1 E] 2 D Antibiotics? . .............. @ I D 2 E] 5.11. drugs? ................. 1 D 2 III Medicines to reduce blood pressure? . . I D ' 2 E] Surgery? .................... _ 1 D 2 D 5.21.143»? — Specify 1 ......... ® 1 D 2 El 9 _ - : Any other treatment. SpecrfyK . . . . :@ 1 C] 2 D 55-. Have you had any trouble with pain due to I kidney, bladder or urinary problems? .@ 1 E] Yes i 2 El No (56) b. 'as the pain located in — ‘ Yes No v... rigbt side mo back? ........ 3@ 1 13 2 a Yo... Mr side AND back? ........ @ 1 [j 2 1:] Botb sides mo back? .......... 5.1 1:] 2 [j The area over the bladder? ........ ® I E] 2 C] Your lower abdomen? ........... @ 1 1:] 2 [:l c. About lion reeny times have you Inad E this pain? : Times _ I ' I 1 1 5" :hslyrEV-ogfijxlru' slsters, l" ; Mother E Father E Sister 3 Brother i No (Anyone else?) ' : l : : I Polyeystie disease of the kidney? ..... E.* I C] : 2 E] E 3 D E ‘ Cl 5 5 [3 Beth chronic nephritis (Kidney disease) l: l l l l and nerve deafness in childhood? ..... :@* 1 D ; 2|: : 3 III : 4:. g 5 D _ 1 I r I KIdneyarbladderstorIes? .......... :@* 1|: : 2:] E 3D : 4D : 5|:| I‘Iigb blood pressure? ............. i@* I D l 2 [3 l 3 D l 4 D l 5 1:] 57a. Did a doctor EVER tell you that you had any of the lollowing in your urine - If ”Yes." ask b and c. b. How man separate times di it happen? a. When did it LAST happen? Protein or albumin? . .' ........... I D 2 D Times Years ago Blood? ..................... :@ 1 [j 2 D ® Times Years ago Sugar? . . . ‘. ................. E. t D 2 D Times Years ago Anything else? Specify“ ......... i. | El 2 D Times Years ago ALLERGIES 53a. Have you ever had skin tests for allergies? 1:] Yes 25mm) I}. Did you ever have a positive skin reaction to - Trees? ..................... Gross? ..................... Weeds? ..................... House dust? .................. Molds? ..................... Bacteria? ................... Foods? ..................... c. Have you ever had allergy shots? Yes No .lr: 2:: .‘EI 2D ECG 2:: ..‘C' 2:: @tD 2:] '@‘1:1 21:] @‘D 2:: @1DYes : 2 D Na d. Have ou ever had any reaction to an allergy i ‘ Y (shot test) which was more than iust a swelling : @ D es around the sides at the (shot/test)? : 2 [3 No 59a. Did a doctor EVER tell you that is. Do you still have . . .? c. How many you had - years ago did you first have it? If "Yes," ask 5% and c. No Yes No DK Asthma? .................... 2 D 3 El 4 [:1 9 [:1 _ Haytever? ................... 2 D 3 CI 4 D 9 [:I Any other allergies? Specify“ ...... 2 D 3 D 4 D 9 D If "Yes" to any condition in 59a ask 59d. otherwise. go to 60 d. Was the doctor - No A General Practitioner? .......... 2 D An Internist? ................. 2 D An Ear, Nose and Throat Spocialist?. . 2 [:I An Allergist? ................. 2 [:I Some other type? Specify‘ ........ 2 D 85 60o. During the past 12 months, not counting colds or the flu, have you FREQUENTLY had trouble with — Wheezing? .............................. Stuffy nose? ....... . ..................... Itchy nose? ............................. Watery discharge from the nose? ................ Post nasal drip? .......................... Watery, itchy eyes? ........................ 7 Itchy ears . ............................. Sinus infections? ......................... Yes :C‘D :th its am: am: 20D l.‘l:l EOE _ _______‘ No 21: 2:1 2C! 2:1 2:1 2D 21:] 2C] CHECK ITEM I > 2D All other (61) i D Yes in 59a or 60a (60b) b. Because of the (allergies/symptoms) you just mentioned have you ever - Token medication? ........................ Moved to a different location? ................. Installed air-conditioning, a humidifier or on air-cleaner? .................. Tried to keep away from the things that seem to bring on the condition or make it worse? ............................... Ask if l7+ Changed iobs? ........................... Yes l.‘C| :00 l.‘E] 5.1:] l.1[:] r l I l l | I l I I | No 2C! 2D 2D 2D 2D D Under l7 c. Do these (allergies/symptoms) you mentioned bother you in the - Spring? ................................ Summer? ............................... Fall until frost? .......................... Fall after frost? ...... : ................... d. Do the (allergies/symptoms) you mentioned bother you — lndoors? ............................... Outdoors? .............................. 2III 2E 2III 2E No 2C] 2E] e. Do the (allergies/symptoms) you mentioned seem to get worse in - Yes No Dry weather? ...................... ' ...... l. 1 D 2 D Rainy or humid weather? .................... E. ‘ D 2 D f. Do the (allergies/symptoms) both you more when E you are around - : Yes No Gross? ................................ 5.1 D 2D Trees? ................................ E. I 2 U 60. Continued 9. How old were you when on lirsf began having trouble with the gallergies/symp'oms) you mentioned? h. Are 'here any ihings or places which YOU, NOT YOUR DOCTOR, associate with making your sympfams or allergy problem worse? @__ Years old 1:] Yes — Specify i. Have you ever had a -— If "Yes," ask 60j. Dog for a pet? ........................ Cal for a pet? ........................ l I l l l l l l l l | l l . 2am I l l | I l l I l l | I j. Do you have one now? Yes No 31:} 4E] 31:] 4D Notes 87 HYPERTENSION 6la. Have you EVER been told by o doctor that you had high blood pressure? I ' Y 6!) :.1C] es( c : 2 [:| No b. Another name lor high blood pressure is hypertension. T Hove you EVER been told by a doctor that you hod l. ‘ C] Yes hypertension? 2 E] No (65) c. About how long ogo were you FIRST told by Is doctor that you hod (high blood pressure/hypertension)? Month s @ Years 0 C] Less than I month 62o. During the post 12 months,obout how many times have -_.I-_---_--_-__- ._--__.-__..__-_ CHECK ITEM J @ 12 Under I8 (76) 2 :1 l8—24 (75) 3 :3 25+ (66) you seen or talked to o doctor about your (high blood - - pressure/hypertension)? @ [:1 N TImes 0 one b. l’las o doctor EVER odvised you to lose wei ht BECAUSE or (HIGH BLOOD Pnessune @ I E] Yes HYPERTENSION)? 2 l3 No 63o. Hos a doctor EVER prescribed medicine for your (high blood pressure/hypertension)? :@ ‘ Cl Yes l 2 D No (64) b. Are you NOW taking any medicine prescribed by a I doctor for your (high blood pressure/hypertension)? :@ ‘ D Yes i 2 C] No (64) l c. How often ore you supposed to take this medicine - l more t’hon once I: doy, once o doy, or less than once l. ‘ [3 More ”‘3" once a day a day. : z 1:] Once a day l a [3 Less than once a day I d. How olten do you talre your medicine when you l , ore supposed to -; all the time, often, once in :@ ' Cl A" the time o while, or never. : 2 El Often I l 3 [:1 Once in a while E 4 [3 Never : s 1:] Other — Specify l I l 64. :OBOKT mom” doys d/I'I'ring the pos; l2 months 1 s ig pressure ypertension kept you D in bed all or most of the day? l. ays l o E] None 65. Durinbg'm post '2 months", how many times wos i your pressure taken. Do not count time‘s - while o patient in a hospital. l. Tunes : o C] None i I I I l I I I I I I l CARDIOVASCULAR CONDITIONS I l 66. Have you EVER had any trouble with pain, discounted, :@ I I: Yes or pressure in your chest when you wall: last or uphill? II E 2 [3 No 67a. Have you EVER had severe pain across the front of : your chest lasting for hall an hour or more? :@ I D Yes l : 2 [:1 No (68) b. How many of these attacks have you had? l :@ I B One I l 2 G 2—3 I l I D 4 or more I c. Are you taking any medication to strengthen your heart l beat or to regulate it? :@ I D Yes I l 2 D No 68a. Have you EVER had shortness oi breath eithev : when hurrying on the level or wallting up a l@ I D Yes slight hill? { : 2 [:1 No (69) h. H‘ave you had this problem for at least 90 days i o the ear? 1 Yes 1 : D I : z C] No 69. Have you EVER had - 3 Yes No Loss at vision or blindness lasting Irom i several minutes to several days? ........... l@ ‘ D 3 D I Dilficulty in speaking or slurred speech : lasting lrom several minutes to several l days? ............................. :. 1 D 2 U Loss ol sensation, numbness or tingling : sensations lasting lrom several minutes : t | d ? ....... '. .............. o severa ays :.,D 2 D A severe head iniury leading to unconsciousness : lasting for more than 5 minutes? ............ : 1 D 2 D Prolonged weakness or paralysis at one or both sides at the body lasting up to several months? ...................... | D 2 D Notes 90 70a. Have you EVER had a stroke? I II.1[:]Yes ZDNOUI) . Did a doctor to“ you this? . How many strokes have you had? . How long ago did you have the (first) stroke? IDYES ZDNO ._ Strokes I |:] One I I I I | | | | I I I l I I I I I I I I I I Years 0 [3 Less than | year If one stroke only, go to 70f . How long ago did you have your LAST stroke? Years 0 D Less than | year . When you had your stroke(s), did you have — 9. Do you still have . . . Notes If "Yes," ask 70g Yes No Yes No Paralysis ol the lace? ............. I D 2 I: 3 D 4 [:I * Paralysis of the arm or leg? ......... :® 1D 2 [:I 3 E] 4 I: I * I I Numbness of the arm or leg? ........ : I D 2 D 3 D 4 [:1 E * Change in vision? ............... I E@*I II] 2 CI a I: a [I I Change in speech? ............... E@ I D 2 E] 3 I:| 4 E] I I‘ I I Any other symptoms? — Specify : ® 1 D 2 [j 3 E] 4 D I * I l I i BACK AND NECK PROBLEMS 71. Have you EVER had pain in your back on r 1 (‘1 Yes most days for at least 2 weeks? I. M i 2 :3. No l 72. Have you EVER had pain in your neck I on most days for at least 2 weeks? :@ 1 [:3 Yes j 2 :1 No 73. Have you EVER had pain or aching in any l joint, other than the back or neck, on most }.1 [“3 Yes days lor at least 6 weeks? I “ l Zfilm I 74a. Have you EVER had any swelling of joints, with l pain present when the joint was touched, on most . 1 [:1 Yes days for at least l month? - ® l 2 E] No b. Have you had stillnhe-s—swin your joints and muscles, l when first getting out of bed in the morning, on most :. 1 I: Yes mornings for at least 1 month? I j 2 E] No 75a. Have you ever changed your job or stopped ' _ working because at a health problem? 1.1 L] Yes I l b. What was the health problem? c. Did you — Retire because at disability? ............... Change permanently to an easier job? .......... Change temporarily to an easier job? .......... Cut down to part-time work only? ........... Have to stop working for a few months? ........ Have to cut down on housework? ............. Stop doing any housework? ................ Make some other change? — Specify 96®9®969 2 [1 No (Check Item K) Yes No ‘E 2D 1t: 2[3 i: 2r: 1: 2m 11: 2L: H: 2B rm 2:1 IE] 2D CHECKITEM K 9 1:] Under I9 (76) 2 (:1 19—59 (80) 3 C] 60+ (78) 91 92 76a. Is -— unending school now? @ 1 E] Yes 2 CI No (50) b. What is the name and address of the school he Name goes to? Address (Number and street) City [State ZIP code 77a. is there a school lunch program at the school he attends? . How many times a week does he usually participate? ® 1|:lYes 2 DNO‘ }(77d) QDDK Times 0 D None (77d) . How much does he pay for his lunch per day? @ Cents o D Free . is there a special milk program at the school he attends? @ 1 D Yes 2 D No } (77g) 9 [3 DK . How much does he pay for his milk per day? 576 Cents o DFree . How many times a week does he usually participate? . Is there a school breakfast program at the school he attends? C3] 9 Times oDNone IDYES ZDNO }(80) eljDK . How many times a week does he usually participate? __ Times 0 [3 None (80) . How much does he pay for his breakfast per day? __ Cents (80) 0 [Z] Free J 780. Do you particpote in any program in which prepared meals OR groceries are delivered to your home on a regulorbosis? I £.1C|Yes 2 El No (79) b. Are prepared meals or groceries delivered to your home? 1 I: Prepared meals only 9 2 [:I Groceries only 3 I: Both 4 I: Other —- Specify :. Is the sponsor of the program - A local health department? ............. Another department of local government? . . . . A State government? .................. A church group? .................... Some other voluntary organization? Specify; _-_-_____.._._______....____-,____ Yes No :gp MI] 2: lap IE] 2:1 leg 1D 21: 1.1m 2E! l.‘l:l 2:] d. About how often is the food brought to your home? 1 D Two or three times a day @ 2 I:] Once a day 3 [3 Four to six times a week 4 [3 Two or three times a week 5 I: Once a week 6 D Two or three times a month 7 [:I Once a month a :1 Less than once a month 9 D Other — Specify r——-—-—-————-——————————————————-———-—-—4—-—— Notes 96 93 94 79o. Do you participate on a regular basis in any programs in which you go out to a place where meals are served to groups of people? 2 E] No (80) b. ls the sponsor of the program— Yes N0 A local health department? ................. 1 [:1 2 D :. Another department of local government? ....... :.1 I: 2 D i A State government? ..................... l. l D 2 |:| A church group? ................... Some other voluntary organization? Specify } 5.1:: 2D 1|: 2|:| c. About how often do you go .out for these meals? 1 [:1 Two or three times a day 2 [:1 Once a day 3 D Four to six times a week 4 D Two or three times a week 5 [:I Once a week 6 [___| Two or three times a month 7 D Once a month 8 [:1 Less than once a month 9 [:1 Other — Specify_ 80. RESPONDENT Mark main respondent i [:1 Sample person 2 D Mother 3 E] Father 4 [3 Sister or brother 5 |:[ Other -— Specify CHECK lTEM L i D Another SP available for interview (Next Medical History Questionnaire) 2 C] No other SP available for interview (Page 3 of the Household Questionnaire) Heath History Supplement, Ages 12-74 Years FORM HRA-II-2 Form Approved "“7"” O.M.B. No. 68-RI502 DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE NOTICE — All information which would NATfig::IHc§::°E%R§§:SEXLNdzTg‘ATT'FS'LCS permit identification of the individual will be held in Strict confidence. will HEALTH HISTORY SUPPLEMENT be used only by persons engaged In (A es ]2_74 Years) and for the purposes of the survey. and 9 Will not be disclosed or released to HEALTH AND NUTRITION EXAMINATION SURVEY II others for any purpose. a. Examinee name (First, middle initial, last) 5- Deck No. C- Sample No- d. Sex e. Age f. Interviewer name , g. Interviewer No. [:iMale E] Female .. _. _ _ READ — I’d like to ask you some questions about health problems or conditions you might have had in the past or might have at the present time. VI 25 or over ask Question | INTERVI w ‘ [if E ER CHECK ITEM I 2 E] Under 25 SKIP TO Question l7 Ia. Have you ever had any trouble with pain, discomfort or pressure in your chest when you walk fast or uphill? D Yes Li] No — SKIP to 20 9“ .1__ N b. Would you describe this pain as any of the following? Yes No Heaviness ............................. r. 11“ ‘Burning sensation ........................ I. i In" Tightness ............................. I. 1 él 2 D Stabbing pm ......................... .E. 1C] 2 T passum .............................. Stab 1i:? 2;" sharp pain ............................. 3.1 1:] 2 [:1 Shooting pains .......................... {.1 Q, 2 fl e. Have you had the pain or discomfort more than THREE times? :1 Yes C] No N d. Have you been bothered by the pain or discomfort within the past 12 months? C] Yes [2 No N e. How old were you when you first had the pair. or discomfort? ago D Under l0 years old C} iO—l9 years old N [7120—29 years old a [130—39 years old U! {j 40—49 years old 0'3 :1 50—59 years old 7 [:3 60 years or older f. Do you get the pain or discomfort if you walk at an ordinary pace on level ground? i [1 Yes 2 E] No i» l. Continued I I g. If you get the pain or discomfort while i walking do you — : Yes No I Sro ? ............................... ' 1 2 p }@ D I: I Slow down? ........................... : 1C] 2 E] l Continue at the some pace? ................ l@ I D 2 C} Take medicine? ........................ E ID 2 [:1 it. If you do stop or slow down, is the pain or discomfort relieved 0! not? 1:] Relieved — Ask i 2:] Not relieved - SKIP to} i. How soon is the pain relieved? 2 C] IO minutes or more J‘. When you get pain or discomfort where is it located? Is it in the - I l | I l I | | | I I l I | I l l IE] Less than l0 minutes I l | | | | | I l I I | | l Yes No Upper middle chest? ..................... ,@ ‘El 2 [:1 I Lower middle chest? ..................... l ® 1 D 2 E] l | Left side of chest? ...................... : @ I E] 2 [j | Left arm? ............................ E I [:3 2 :1 I Right side of chest? ......... : ........... :@ 1 [j 2 [:J I Some other place? Specifyz .......... . . . I S I E] 2[:| l I k. Do any of the following things tend to I bring the pain or discomfort on? i i Yes No I Excitement or emotion ................... l @ i Cl 2 [j I Stooping over ......................... E I C] 2 E] l Eating 0 heavy meal .................... i 1 Cl 2 [:l | I Coughing spells ....................... i I [:1 2:] I Cold wind ........................... l® ID 2D Exertion ............................ E @ 1 C] 2:] 2a. Have you ever had severe pain across the from of your chest lasting for half an hour or more? l®1DYes ZDNo—SKlPto3 b. How many at these attacks of pain have you had? 1 C] One 2 D Two 3 D Three 4 D Four or more c. What was the date of your last attack? _ .._Month _ _Year d. What was the duration at the pain during your last attack? @ ® 1 C] 30—59 minutes 2 D |-—2 hours 3 C] 3—5 hours 4 C] 6—I I hours 5 D I2—23 hours 6 I] 24—47 hours 7 [:I 2 days or more e. Did you see a doctor about this last attack? IDYES ZDNo—SKIP tog i. What did he say it was? IF ENTRY IN 2f SKIP TO h; OTHERWISE ASK g DATA PREPARATION USE ONLY 01D 01D 01D 01D .1EI .1I:I 01D 01D 9. Have you ever seen a doctor about chest pains, chest discomtort or heart tailure? '. IDYes ZDNo—SKlPtoi 4 D l0—l4 days 5 |:] l5-l9 days 6 [3 20—29 days h. What type of doctor was it? Was it a — Yes No 00,11! know General Practitioner? .................... :. ‘ D 2 El 9 D lnternist? ............................ 1. I D 2 D 9 D I Osteopath? ........................... : 150 I D 2 U s D Heart specialist? ....................... i® 1D 2 [:1 9 [I Some other medical ' person? — Specify i@ 1:] 2 D 9 D i. Have you ever stayed in a hospital overnight or longer l because of your chest pains or a heart condition? :@ ‘ Cl Yes : 2 [3 No _j. During the past 12 months, about how many work days l would you estimate you have lost because at a l. ‘ D None heart condition? I 2 |:] l—4 days I 3 C] 5—9 days l l l I | I | 7 [:1 30 days or more 97 SHORTNESS 0F BREATH 3a. Have you ever had shortness of breath either when hurrying on the level or walking up u slight hill? IDYes—Askb 2E1N0—SKIPto4 6 CE) I I I I 1 I _ 1 b. Have you had this problem on most days for l at least 90 days in the past year? E 1 [:1 Yes l 2 [3 No I c. Do you get short at breath when walking with other l people at an ordinary pace on level ground? : @ 1 {:1 Yes E 2 D No d. Do you have to stop for breath when walking at l your own pace on level ground? 1 1 E] Yes E 2 1:} No e. Do you have to stop for breath atter walking about l ")0 yards or alter a few minutes on level ground? : 1 D Yes I : 2 D No i. How long ago did you first have this trouble with l shortness at breath? l I C] Less than I year ago I I 2 [j |-3 years ago I : 3 1:] 4—9 years ago l 4 {:1 l0 years ago or more I E 9 E] Don't know g. Hove you gotten chest pains along with the shortness ' of breath? E 1 [:1 Yes _ Ask h : 2|:)No—SKIPtoi J h. Were these pains located in the — : Yes No Upper chest? .......................... E 1 [j 2 D Upper back? ........................... E 1 E] 2 D Lower back? .......................... E ‘ D 2 D Along the lower ribs? ...... .............. E 1 I: 2 I: On the sides? ......................... E 1D 2 E] i. Do you develop wheezing as well as shortness of breath? : l I (3 Yes : 2 E] No I Notes 4a. Have you ever had pain in your back on most days for l at least two weeks? :.1 [3 Yes 2ENo—SKlPt05 b. What is the longest episode of back pain you have ever had? 6 I [:1 Less than one month 2 {j One but less than 2 months 31:32—3 months 4 [7] 4—5 months 5 C] 6 months or more 9 [:1 Don’t remember c. Where is the pain usually located? ____ ______-__.._-__..__I __ Yes No In the — | 7 Al Upper back ............................ :. 1 CJ 2 E] Mid-back? ............................ E@ I I3 2 g I L ? .......................... ower back l@ 1 C] 2 D If only one marked ln c, mark d without asking. , l d. When you have this back pain, where is it : most intense? I Yes N° I Upper back? .......................... :@ 1 [:1 2 E] I I Mid-back? ............................ l. I CI 2 [:1 Lower back? .......................... l@ 1 C] 2 [:J l e. Is the back pain usually present when you are ' resting at night? l. 1 [:1 Yes I l 2 [:3 No 6. When you have the back pain does it awaken you l from sleeping at night? :@ I C] Yes ' 2 E] No I 9. Does the back pain ever seem to spread? l :.1 [1 Yes : ZDNo—SKlPtoi h. Does it spread to the - : Yes No | Back of the right leg? .................. . . :.1 [j 2 E] I . Back of the left leg? ..... . . .............. {.1[:j 2 l: I Back of both legs? ................... ... l. 1:] 2 E1 Top of the head? ..................... ;.1|: 2:] Sidesotthebody? ......... 2.1:] 2D i. Is your back pain made worse - E Yes No By coughing, sneezing, or deep breathing? ..... '. . l.1 E] 2 C} With bending or twisting motion? ............. I. I E] 2 D After prolonged sitting? ................... 1.1 |:] 2 D After prolonged standing? .................. l.1 El 2 D After prolonged activity? ................... :.1 [j z D I 100 Continued J'. How old woro ou when you first oxporioncod this rocurting och pain 1:] Lessthan 20 years old 2 B 20—29 years old 3 C] 30—39 years old a [3 40—49 years old 5 B 50—59 years old 5 E1 60 years old or older :- . Whon was tho lost timo you had this pain? 1 [3 Have it now 2 D Less than I year ago, but not now 3 C] 1—2 years ago 4 [:1 3—5 years ago 5 C] 6 years ago or more l. Does this hock poin occur more troquontly now than it usod to occur? ‘ D Yes 2 [:3 No m. Hos this hock poin usuolly boon mild, moderate or sovoro? I E] Mild 2 E] Moderate 3 D Severe n. Hove you over had a sproinod hock duo to some typo of physical activity? ‘ Cl Yes 2 E] No 0. New you ovor had a dlsc problorn in oithor your hock or nook? ‘ C] Yes 2DNo-SKlPtou p. Wos tho prolalorn o rupturod disc? I E] Yes 2 E] No q. Wos tho disc problem in your buck or nook? m 1 E] Back 2 C] Neck 3 [:3 Both r. How old wore you whon you first had tho disc problorn? ._ _ Years old s. Woro you in traction? 96 l : 1 C} Yes l 2 [:1 No l t. VI ? ' os surgory nocossory i 1 E] Yes : 2 E] No u. Hovo you ovor stoyod in a hospital ' ovornight or longer for back pain? E ‘ El Y” : 2 [:J No 5a. Have you ever had pain in your neck on :@1 D Yes most days for at least two weeks? 2 [3 No _ SKIP TO lNTERVIEWER CHECK ITEM : b. What is the longest episode of neck poin you have ever 'had? 9 1 CI Less than one month 2 [:1 One but less than two months 3 C] 2—3 months 4 C) 4—5 months 5 C] 6 months or more 9 [3 Don’t remember c. Is the neck pain present when you are resting at night? ; g :35 o d. Does the neck pain ever seem to spreod? 1 Cl Yes ZDNO—SKlPtof I l I l I | I I I I l I I I I l I l I l I I I E e. Does it spread to — I Yes No The top and back of the head? ............... :.1 El 2 [1 Either shoulder area? .................... E.1 CI 2 E] The «ms or hands? ...................... :.1 [:1 2 [j I Other? —- Specify l. 1 [j 2 [:l f. Is your neck pain mode worse - I Yes No By coughing, sneezing, or deep breathing? ...... {.1 D 2 CI . . . I WIth bendIng or twisting rnotlon? ............. I. I D 2 C] After prolonged activity? .................. :® I I: z D l After prolonged sitting? ................... [@ I [:I 2 C] After prolonged standing? .................. I® ‘ l: 2 E] 9. How old were you when ou first experienced this l recurring neck pain? Y :. l g LOeSZJhan 20 13am Old I 2 2 — years a E 3 B 30—39 years old I 4 I: 40—49 years old I 5 I: 50-59 years old I s [j 60 years old or older h.Wh- thltt' hdth' ".7 ' on was e os me you o Is paIn :@ ‘Cl Have it now : 2 :1 Less than I year ago but not now l 3 [:l l—2 years ago I 4 C] 3—5 years ago I s [:1 6 years ago or more i. Does this neck poin occur more frequently now than l Y it used to occur? :. $3] N? I j. Hos this neck poin usually been mild, moderate, l - or severe? :@ 1 E] 2": 2 t l [:1 o era e I 3 [:] Severe k. Have'you ever had a "whiplash" iniury ' of the neck? l. 1 D Yes I 2 D No I [ INTERVIEWER CHECK ITEM II - If "Yes” in Questions 43 or Sa, (i.e., back pain or neck pain), ask questions 6—I0; otherwise SKIP to Question ll 101 102 60. Have you ever used any oi lhe following kinds of treafmem for your back or neck trouble? 1 6b. Did it do you any good? Yes No Yes No splines or com .................... :.1[j 2 [:1 11: 2:] Braces ......................... E@1:] 2[:] @ 'L] 2T] 1 Diafherrny or paraffin ............... l@ 1 [:1 2 E] 1 1:] 2 g; 1 Ho? packs or heating pads ............. l@ 1:} 2 E] w 1 a 2 LE 1 Cold packs orice ................... 5@ 1B 2B 1:] 2:» Reese ........................... §.1E] a: .1D 2i] Trac1ion ......................... l® 1:] 2C] @ 1:] 2['_‘] Exercises or physical fherapy ........... §@ 1 1:1 25 1 1:] 21:1 Aspirin ......................... l@ 11:] 2C- 1D 21:] Cane .......................... :@1E} a: .1D 2[:] Crotch ......................... l® 1m 2 [:1 1E] 2 U 1 Stiffmamess ...................... E. 1[:] 2 E] 1:] 2 E] Bedboord ....................... l® 1C] 2:] .1E] 2§J E If "Yes" to 60 and b, ask: 1 c. Are you now using it regularly for your : back or neck trouble? l Yes No Splints or «am ................. l. 1 [j 2 C Braces .............. - ............ i. 1 D 2 [j Diathermy or paramn ................. E. 1 [1 2 g Hov packs or heating pads ............. 1@ 'E] 213 Cold packsar ice .................. l.1:1 21:] Resr ........................... 11.1 [:1 2 [:1 Traction ......................... E@ 1 E] 2 E] Exercises or physical therapy .......... l@ 1 C] 2 [j l Aspirin ......................... ‘l@ I D 2 C] Cane ........................... i 1 C] 2 E] Cruich .......................... E@ 1 D 2 E] 51111 mattress ..................... l. 1 1:1 2:] Bed board» ........................ l@ 1 D 2 D 7a. At the present time, does your back or neck condition restrict your physical activity very little, quite a bit, or a whole lot? 1D Very little 2 D Quite a bit 3 [:1 A whole lot Have you ever had to stay in bed at home for long periods of time because of your back or neck trouble? pain, swelling, or stiffness which might still be present? 6 IDYES ZDNO 9 E Don't know l l I I I I I i I I I l 1 E] Yes I I 2 Cl No c. Have you ever stayed overnight in a hospital because : of back or neck problems? l 1 Cl Yes I : 2 E No l 8. With respect to your back or neck trouble, would 1 . . . . 7 , you say your condition IS mild, moderate, or severe. {.1 El, MIId I l 2 [:1 Moderate I I 3 C] Severe I 9a. At any time during the past year did your back or i neck trouble cause you to cut down on the things you I ‘ Yes usually do? :. D l ZENo—SKlPtoIO b. During the past year, about how many days did you l cut down on your activity? l. _ _ __ Days I I l oooSNone—SKIPIO l0 c. During the past year, about how many days did 3 your condition keep you lrom work or school, not , __ __ __ Da 5 counting work around the house? I. y I 000 C] None d. During the past year about how many days did your 1; condition limit the kind or amount at work around ,. _ _ __ Days the house you could do? : I oooDNone—SKlPto l0 e. During the past year, about how many days has this l condition kept you in bed all or most of the day? i. _ _ __ Days | I l 000 C] None 10a. Have you ever had pain, swelling, or stittness in your 3 back or neck as the result at an accident or iniury? I _ :.1 D Yes back i 2 D Yes — neck I l l 3 [:1 Yes — both I l aleo—SKIPtoII I b. Do you think the accident or injury is the cause of any i l I l l I I I J 103 104 Ha. Have you ever been treated by a medical person tar back or neck trouble? .1DYes 2DNO-SKIP to I3 b. Was the medical person a — General practitioner? .................... Internist? ........................... Osteopath? ., ......................... Physical therapist? ..................... Occupational therapist? .................. Other? — Specify Yes No §.1I:1 2:1 :@1:1 2:: 5@1m 21:1 ?@1:1 211 i®1m 2:1 l@1f:l 2D 3.1:! 21:] E@1E1 2:] :.1D 2:1 c. What did he say the problem was? DATA PREPARATION USE ONLY .1|:] .1D .1[:| .1E} d. Are you now being treated by a medical person tor back or neck trouble? e. Is this a — General practitioner? .................... Internist? ........................... Rheumatalogist? ....... ' ................ Orthopedist? .................... Chiropractor? ......................... Osteopath? . . . . . . ................... Physical therapist? ..................... 0c cupational therapist? .................. Other? - Specify .1EJ .11: l.IDYes 2[:]No -SKIPto 12 Yes No I‘ll: 2D EOE 25 5.11:1 1D i01m 2D E.1D 21:1 5.1m as 5.1:] 2:1 i.1m 21:1 l.1[:] 2D __.._,__..__ t. What did he say the problem was? DATA PREPARATION USE ONLY 1 E3 1 :1 1 E3 1 I3 1 [:l 1 [:1 12a. Have you ever had an operation for a back or neck disease 0: iniury? E iEtes 2[:lNo —SKiPto I3 1:. Was it your back or neck? c. What was the opevation? 13a. Have you had pain or aching in any ioint other than the back or neck on most days for at least six weeks? 9 1 [:1 Back 2 [3 Neck 3 E] Both IE1Yes —Ask band c 2[:]No— SKIP to I4 5. Which ioints were painfuI? Fingers ........................ 99®®6999 Yes No 13 2’1 1:1 2:1 1:1 2:1 ‘D 2:1 1C1 25 1:) 2D ‘D 2E] 1: 2:] c. If "Yes,” — Which? Right Left .‘E 2E] .w: 2m .‘El 21:} @c] 2D @113 2D @‘m 2D @‘m 2C] .'D 2:] Both 3 [:1 3C] 3C] 3E] 31:} 3E] 3C] 3:! d. When was the last time you had this pain? 6 1:] Have it now 2 E} Less than | year a 3 B l—2 years ago a C] 3—5 years ago go, but not now 5 [:i 6 years ago or more 105 106 14a. Have you ever had any swelling of ioints with pain present when the io‘int was touched on most days in! at least one month? @ IDYes—Askb ZENo—SKlPtoIS b. Has this swelling been present on any one occasion lor at least six weeks? @ 1E]Yes ZDNO c. Which ioints are usually involved whenever you have this swelling and tenderness on touching? Fingers ....................... Wrists ........................ Shoulders ...................... Hips ......................... Ankles ........................ Feet ......................... @®®@®®®® ’———> d. If “Yes." — Which? Yes No Right 1E] 2D.1l:1 1:1 2E] .1E] 1:1 2E1.‘D 1:1 2E1.1l:l 1E] 2E] @fl 1:] 2E] .1D 15 211.1Cl 1E 2:1.1m Left 2 Cl 2:] ill—J 2:] 2D 2E] 2C] 2U Both 3 Cl 3C] 3E] 3C] 3D 3D 3D 3:] e. How old were you when you first experienced this swelling of the ioints? a 1 C] Less than 20 years old 2 [:1 20—29 years old 3 [I 30—39 years old 4 [3 40-49 years old 5 B 50—59 years old 6 1:] 60 years old or older i. When was the last time you had this? 1 [:I Now 2 {1 Less than I year ago, but not now 3 E] l-2 years ago 4 C] 3-5 years ago 5 [j 6 years ago or more 15a. Have you had stillness in your ioinls and muscles when first getting out of bed in the morning on mos' mornings Ior a? least one monfh? iDYes —Ask b 2[] No —SKIP to lo I:- Has this morning stillness been presenf 1 I I l I I l l on any one occasion for at least six weeks? : 1 :1 Yes I 2 [3 No c. Which joints are usually involved whenever l a. If "Yes," _ Which? you have this morning stiffness? { fi—fi E Yes No Right Left Both Fingers ...................... i.1g 2:1 .113 2D 3:] Wris's ....................... l.1[j 2g .1[j 2D 3D Elbows ....................... 5.1g 2l:l .15] 2E] 3g Shoulders ..................... l 1D zij 1E] 2:] 3:1 Hips ........................ §@1ij 2E3 @flg 2:? 3:] Knees ....................... 5@1[’j 2D .1C] 2:] 3:] Ankles ....................... §@i[:‘l 2:] .13 213 3D Feei ........................ E@1m 2g .1E 2E 313 Bock ........................ l 1 r3 2 [j e. How long after gelling up and moving around does the morning stillness last? 6 1 [:1 Less than l5 minutes 2 [3 l5 minutes to one half hour 3 [:I More than one half hour. but less than all day 4Q All day I. How old were you when you first experienced this morning stiffness of joints? 9 I ['1 Less than 20 years old 2 B 20—29 years old 3 [1 30—39 years old 4 B 40-49 years old 5 B 50—59 years old 6 l: 60 years old or older 9. When was the last lime you had Ohis? ______-_____._.....__1____.___._______________._____._________ -_ il:lNow z D Less than I year ago, but not now 3 C] 1—3 years ago 4 C] 4—9 years ago 5 [:1 [0 years ago or more 107 loo. Have you ever had a iob which placed frequent stress or strain on your back? t[:]Yes 2DNo—SKIP to i7 . HOV 'ong did you work at that kind of iob? __ _ Months OR __._ Years 17. Has a doctor ever told you that you had ‘ mononucleosis? l I D Yes I : 2 E] No We. Have you ever had yellow jaundice which ' caused your skin or eyes to turn yellow? l i C] Yes I ' szo—SKlPtog b. When this happened, did your urine i I become darker? l i [3 Yes i I 2 1:] No . Did your stools become lighter in color? : . . Q 1D Yes I i 2 {:1 No I . Did your skin remain yell’ow for a month or longer? ' E 1 [:1 Yes l 2 D No . Have you had yellow iaundice more than once? 3" I [:1 Yes 2C]No—SKIPtog . How many times did you have it? _ __ Times . As for as you know, have you ever been in contact with a person who may have had yellow iaundice? @® 1 D Yes 2 C] No 9 E] Don't know 19. Have you ever had on operation for a hernia not including hiatus hernia of the diaphragm? IDYes 2[:]No 20. How many times have you used or had any contact with carbon tetrachloride? (Used. for example, in dry cleaning) 0 Cl None 1 El Once z C] 2—4 times 3 [3 5—9 times 4 [3 ID or more times 9 1:] Don't know 108 No. Are pesticides, such as weed killers, insecticides, during your entire lite? l I tun icides and other chemicals used for pest control, ' Yes No Don't know 9 I used in your — I _ *- Hame? ............................. I 1 CI 2 7‘4 9 L__I I Garden? ............................ 1 @ 1 CI 2 I: 9 C I Yard? .............................. I 1 [:1 2 El 9 [j I Place at employment? ................... I it] 2 CI 9 I: | Anywhere else around you? — Specify; ........ I 1D 2 D 9 D l I ifALL “NO's” in Zia, ask b; otherwise ask c I I b. To your knowledge are any pesticides I used around you? I ‘ I:I Yes I 2 E] No c. During the past 12 months, has anyone in ' your family had pesticide poisoning I 1:] Yes diagnosed by a doctor? ‘ 2 E] No 1 c d. During the past l2 months, has your home or ' place of employment been treated for pest l ‘ El Yes control by a commercial company? I 2 [:I No I e. Are any disiniectants, such as Lysol or I #1 Pine Oil, used in your home? “ ‘LJ Yes I 2 [Z] No If Age i2—I7, ask 22; otherwise SKIP to Question 23 : 22a. Have you smoked at least l00 cigarettes : I D Yes — Ask b I I 2C] Na—SKIP to 23 b. Do you smoke cigarettes now? 9 1DYes—Askc ZDNa—SKiPtod c. On the average, about how many a day do you smoke? __ _ Cigarettes per day Enter answer and SKIP to e n. . How long has it been since you smoked cigarettes iairly regularly? 77 I: Under one year — Ask e _ _ Years — Enter number of years and SKIP to f as D Never smoked cigarettes regularly — SKIP to 23 99 [:1 Don't know — Ask e e. 0n the average, about how many cigarettes 85 I: Did not smoke 99 I: Don't know f. During the period when you were smoking the most, about how many cigarettes a _~ d day did you usually smoke? _ — Cigarettes per ay 99 {:1 Don‘t know 9. About how old were you when you first started smoking cigarettes fairly regularly? __ _ Years old 38 C] Never smoked regularly I I I I I I l I l I l I I I I l I l l l I l l l . , I a day were you smoking 12 months ago. I‘ Cigarettes per day I I I I I I I I I I I I I l I I l I I 99 [3 Don’t know I 110 23a. Did a doctor ever tell you that you had chronic kidney disease? I :1 Yes 2 D No b. Have you ever had pain or burning sensation on urination accompanied by more frequent urination than usual? 1 [:1 Yes i r l l l l i i i | | i I I l i i am No — SKIP to 24 c. How many separate times has this happened? ‘_ _ Times 24. Do you NOW have difficulty starting to urinate? i 1 D Yes I i 2 [:] No 25. Do you NOW have periods of waking from sleep l two or three times a night to urinate? I, I D Yes I i 2 E} No i 26a. Have you ever noticed blood in your urine? I (FOR WOMEN — other than at the time of your period) I [:1 Yes 2 D No — SKIP to 270 b. How many separate times has this happened? c. When was the last time it happened? 1 [3 Less than I year ago. but not now 2 E} l—2 years ago 3 [3 3—5 years ago 4 E) 6 years ago or more Notes 27a. 0‘ 9 d. a. a: =- . Have you ever noticed that your urine was a ditterent color than the usual yellow? (FOR WOMEN - other than at the time of your period) 1[:]Yes 2D No — SKIP to 28 . How many different times has this happened? 1:] Once 2D Twice 3 E) 3 or more SKIP to e How old were you when it happened? __ _ Years old How long did the change in color last? 1D One time 2 C] One day 3 [3 2—6 days SKIP toh 4 [j l week or longer . How old were you when it FIRST happened? __ _ Years old . How long ago did it lost happen? ________ ____,_.____________ _____________.___ __-___..4 _ _ Years ago . How long did the change in color last that time? Did you see a doctor about it? . What did the doctor.say the problem was? o C} Less than one day _ _ Days 1E]Yes 2[:]No-SKIP to 28 28. Do you have trouble with your bowels which makes I} you constipated or gives you diarrhea? l 1 El Yes — Constipation l 2 D Yes — Diarrhea I 3 E] No l 29a. Have your bowel movements ever been white, gray, : dark black, or streaked with blood? : t |:] Yes l 2 D No ’-— SKIP to Question 300 | b. Which was it? l : Yes No mm. ............................... } ‘El 2E1 . . Gray ............................... l @ 1 E] 2D | Dark black ........................... I @ 1D 2:! Streak ed with blood ..................... @‘EJ .2C1 111 112 30a. Do you have a physical disability or handicap such as the kind or amount at work that you which prevents or limits normal daily activities, l @ ‘ [1 Yes I I can do, housework, schoolwork, using public transportation and so on? I I b. What is the physical disability or handicap? c. How long have you had this disability or handicap? 2 [:1 No — SKIP TO INTERVIEWER CHECK ITEMIII @ _ _ Months 0R _ _ Years d. Does this disability or handicap PREVENT you tram . . . . (Age ‘8 and over) working at a iob or business? .................. (Age 18 and over) driving a car? ......... (Under age 18) doing any regular school work .................. Using any public transportation such as buses, trains, and so on? ........ Taking care of any at your personal needs such as dressing or eating? ........ Doing work around the house? ........... we @ e. Does it LIMIT you in this activity? Yes No Yes No 1D 2:1.1m 2C1 1:] 2:1.1CI 2:] 1:] 213.1EI 2:] 1E: 2E] @1EI 2D 1:1 2D Ow: 2:1 1D 2E] .1EJ 2m INTERVIEWER CHECK ITEMID: 6®®®® 1 I: Female — Ask Question 3I 2 I: MaIe — END OF QUESTIONNAIRE 31a. How old were you when your periods or menstrual cycles started? _. _ Years—Ask b 02 I: Haven't started yet - END OF QUESTIONNAIRE b. Have your periods stopped entirely —-— not counting pregnancy? @ 1[:]Yes ZDNO—SKlPtOd c. At what age? @ _ _ Years — SKIP to 32a d. When did your last period or menstrual cycle end? .__-___-_._‘____________._._ ._._______-._ _ _ @ 00 [:j Having it now — —— Days ago 32o. Hove you taken birth control pills during the past six months? @1DYes—Askb 2[:]No—SKIP to 330 b. Are you taking them now? @ 1DYes ZDNO 33o. Have you EVER been pregnant? 1 [3 Yes -- Ask b 2 E] No - END OF QUESTIONNAIRE It. What is the total number of pregnancies you have had? @ _ __ Number c. What is the total number of miscorri ages you have had? _ _ Number d. What is the total number of live births you have had? _. __ Number e. Are you pregnant now? 99 IDYes—Askf 21:] No SKIP to g 9 [:1 Don't know I. Which month of pregnancy are you in? __ ._ Month 9. Have you had a pregnancy which ended within the last twelve months? @® 1 E] Yes - Ask h 2 [:1 No — END OF QUESTIONNAIRE h. How many months ago did that pregnancy end? @ 1E] l0—l2 months ago 2 C] 7—9 months ago 3 [:1 4—6 months ago 4 [3 0-3 months ago i. Are you breast Ieeding? I l l I | | | I I I | | I | v I I I I I I I I I l l 1 I l I I I I l | | I I I I I T | | I I I l l l I J I I I I I I | I | | l I l | | I I I I I I | I I I I | | l | l l I I I @ thes 2C]No END OF QUESTIONNAIRE Notes 113 17“. Form Approved, 01.8. No. GO—RISIN m,“ HIS-MM ozsAnwqu as «nun, :nucnrou, Ann our“: ”m n, I! i H M" or; .u 0F «my:‘é‘EEL‘A’SECFIVA‘fiZX'SE. my mmmmv “1.0M“ “N" R m, "an" “MM.“ NOTICE — All rnlonnalron much would petrnrl rdarlrlrcalron ol rm mdrvrmal Mll be held HEALTH AND NUTII‘I’ION EXAMINATION SURVEY [I J grrcjrmnlrderrce, mll [9&me hy persons engaged III and lor the purposes ol the 31 I1 II DIETARY _ 24 HOUR RECALL AND DIETARY FREQUENCY "w' " " "°' “' WM” ””5”" “’ “m” '°' "’ “Ms‘ PUNCH A IEI CARD FOR EACH FOOD ITEI § D." 0' one: :fl‘.’ : Srze 0! ed bl g 3 mm In“. E Foods mo beverages consul-ed ' ' Yune L I = r u n m“. sum-u Senal Column § Wm” 9! rear. g :3: ”run, our Ion sen/t6 “V g (‘1'; '3. i m ’ 0-‘Y g No. ,3 Ionm Day Year 3; mm nay var g c Fm De _ I ” . n I" E _ wrn non r-s u-rr u.u "—15 s rv-n u zA-n 3-: 11-): “—34 n x ”-11 "- a». "4. she: n-u , I I T I I I | I | I I I I I I I | I I | l I | u CODING GUIDE ' :12 Respondent code roormm r6; Se: code (use hrgnesl awlrcable code) (Calm 23; 7 77—757 u l » Sample person I - Ilale Is 2 — Spouse 2 — Female except pregnant or hreasl leedrng .; 3— Parent 3 » Pregnanl (l—l rrronllrsl 01 l - Granwarenl I» Pregnanl (5—9 mums) u 5— Comhmahon ol above 5< Breast leedmg u 6 — Olher 6 — Breasl leeding/oregnanl l 1—! months) III 11 Ingeslmfl perrod code mull-m :m I — AM. 2 -- Noon 3 - Between meals ! » PM. 5 - Total day 7 — Breast leedrng/oregnml (5-9 months! Food source code (Comm 511 l — Home 2 - School 3 — Restauranl ‘ — Olner QUESIIONS FOR COLUIMSGI 65, and 66 S4. ls no you a: yearly he only you usually ea? 1 — Yes 2— Mo. rlr 3— No, no money I - Nn, Sunday or Hnlrday 5— No, other reason ~ Speclly Aouanbalg Amara pun [[8093 won vz—Annarq D64 65. Has your diel charged merrily? 0 - No change I > Yes, ealrng more 1— Ves, ealrng less Ens, on is presumed drel » Sphofrly rm.- ‘5 66. Hur- on lines a we: a: you el 1 ml II a "slur-ll? II - Seldom, never 1 , I r I lrlncs I — .r _ b rum 3 — for more tunes D“ SH DIETARY FREQUENCY NUMBER OF TIMES CODE INTERVAL CODE on — Mme or never 0 - ever 7 - Less Ihan ance a week CODING ‘ 99 - Unknown 1 A Dally 9- unknown 77 » Less lhan once a week 2 - Weekly Rope-l coll-ul- v — 15 mt emu-ms 1 — 16 In“: Inlewnl Iran and up. 1 m... em up. l u , I lo. M 7, l I ' — s; o n Mum m" mm“ I Sula! we and on cllonc humus Conllnued 53.;- W7 1 " I I "I I b. Collne a: In I I9 I 0 DI W 7 0 DI I! 7 9 l.I :II‘Illghfig‘aielzm on cereals: and mllk nuoflucls I I I I "L Oneal: 713mm“ celeals ”he, my I I I I l .. . . . I I I I as tolnIIBKCS or cooked sucn as nalmeal ll. Salty snuksllnclpulng pm“. 01105. “.57 l) I 01 :I‘I 7? . M ., V A n 2;"..2"'12..”.“.."§f.§2?.°“2a.‘.I°7‘° 1 TI 0 I “I“I 7 I a. man. can maelsullclz-mng :llead. . an.“ o m m 1 s - . Ial's. blSCuIIS, muIIlnS, com DIEM. IL Sklm mllk or bullelmllk ,,,,,, I I I I Cla(K(‘ISe plclzels- ,,,,,,,,,,,,,,,, I :I 2: II, Fmils and . _ u 19. codevlJ-elaly llemencyl '3'" a All klnas. flesh. canned. Ilpzen n.2- t-IW "Mk. "39 “53”. 0' Pfldflmfii I! l m] '1] 7 I cooked. or law. lulces, lIIICIul‘IIflfl o [m I '71 7 I 9 6 '6) made wulh mllk ............... I I I I Tang a: hull dunksr '. . .................... I I I I . Cam numbel - 3). he you “in villains or minerals? :- 13-11 D - No h. Flmls and vegetables nch ln 0 mm" 9 l - V25. 'eKMHIIY u “m." Drclaly Inlerwemr see 1. Cheese and cheese dlshes ........ my..." ms“ “games, . . . ________ 1 - Yes, IllefluluIy your wan»; ._ Vllamlnflllnelal codes 3| 25-30 a — Unmvm. wesmnhons I - Magnum". mln add-non! 1‘ umnmchmmg heel, Wk. lamb, veal. c. Funds and vegetables nch m o Elli] 7 9 x — MOI-9|! mam-us suwlemenls luncheon meals, canned mealsl . . wlamln C lSee gudelmesl . . . . ........... z - MumpIe man-ms mlh mums. 11 - Ln 1:— 2...: ml. mammal mlemenls ._.‘ a- “halt manna and m-nouls n _ a ellmms B—eomnlel. 12.8“: ad all-ally all" mm :14: o :1 ‘- W‘Ivle VII-NM W ""an will 24— a man-ms, Bvcemplel mu. 3. Poullryllncludlng chlcken, lulkey, duck, llncludlng all candy knulald soll DI I 7 9 s _ 3”” ”Wm 25_ 3:12;: 5"” m'" game buds. culnlsh hen, elm ................. I dunks lemonade. llmeadel ................... I I I I ‘ _ mm” mm", m". I,“ K _ Pmssmm mm ”mm“. —~ I - Iron vnlh fldlhonil snowmen“ SuleEmm :1 I3. Desserlsmd swelsllncludlng cake. :7 I - Gel-Io! H - Fllmme l Dual umlmclmlmg Ilvel kldney “A. o m m 7 flillfgluks'iieI'gag‘l‘?"gs' mm 35-: “ I I“ ‘0 7 9 s - van... E a - mum» wllh mums: . . , , _ supp anenls huall, spleen, ech ......................... I I I Exceplvons we mean. It: mllk .............. I I I I :- 33:12 i m... mm“ ”mm“ 2: - Mlscellmus: cod we. all bvewu‘s . . . . u _ van... A M!" zddlllonaI supplemenls :fi:::;1§;1,{;‘:1‘;:;"lgf;:‘ [12:21} 2.. ,4, ‘° 15' r"7dd"°l"' dust-lea "'3' starch ,4. n n - Vuamu. n mam: Meme 3,. bone mum. nlIoIem o D! n 7 me u lng casselu es. pnl mes, “J m I '2] 1 I g "_ WW" 0 m", mums. “mm“, nllls ammo 3cm pulls mvnlmal _ . nlzza. spagnelll mlh meal, elc.l “ _ mm" 0 mm (manual: 5, mm or shellfish ......................... I I I I Excepnnns Plaln cheese drshes . . . I I I I u _ mm... 0 rain mmonal smlemeflls I ' Safe. 5 ‘ n 16. Alcoholic memes —— u 11 - Calcnum ”m 'e s- so n-.. o m n 1 ,._.2 n m '2 1 9 mm Mammal swolemenls ___________ I I I I ._ Bee, H _ _ _‘_ _ _ _ I > > _ ‘ . ' _ WYERVIEWER: An mly .I Input-don! u .9. 20 a oval 2L lbwofluhmmmesaluunmme? . .‘ finely, never 1 — Frequenlly, zlways ““' o m I: 7 4‘ ‘5 o m '2 7 , Oeeumnally, seldom n _ "A, 7. mpilmlIk and walel based. glavues. saucesl ....... h. l‘une ................................. I I I 15-7) 8. FTsdmI oilsIlgcdlufllnk bungl, malgallne, " l. . .1 . . 22. mummy; code saa ol s,saa 1mm 5. acun tlfllll - ‘ cheese. cream, peanul “5‘“ o m '7 7 m 23. Complellon code - 5mm... any compliant! em. other mu. “I” an...” .2“... " nolmally cveaml . . V . ..................... c. Dlslllled Ilnunl ......................... I ‘ W'9‘“ “"5““W ;‘ I”? "":"’" a” _ _ n mm mean e !. Lap-es In! nuls Inltllgmg my beans and —' .3 17. Sugar he: all! low uloric beverages . 51 l - Rel-ml s - Dine: peas llkl- pmlp beans l beans IO>II no.“ hlack eyed peas ncmnls soy Deans 0 0| '2 7 a. Cold dunks, as above. aIIIIICIHY 0 mm" 9 say "mugs. PIC y_ _ . _ swcelened av Dlel Dunks c“ "I...” u-u WW. II n—lo go. I“ OMTIMIE IN NEXT COLIN" g cm name: 4 '0le e 3 mu... mull! ll 1-") an!) noV-uz 116 Dietary Supplement, Ages 12-74 Years Form HRA-ll-3 l5-t7-76I DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE PUBLIC HEALTH SERVICE HEALTH RESOJRCES ADMINISTRATION NATIONAL CENTER FOR HEALTH STATISTICS HEALTH AND NUTRITION EXAMINATION SURVEY ]I DIETARY SUPPLEMENT AGES 12-74 Form Approved: O.M.B. No. 68-Rl 502 NOTICE — All information which would permit identifi- cation of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposes of the survey and will not be disclosed or released to others for any purpose. a. Deck number b. Age (1-3) 313 (4-5) __ Sample number (6-10) _____ INSTRUCTIONS might have that can affect your nutrition: applies to you. This section of the examination contains questions about diets. medicines and problems you For each question check the answer box which best Ia. Are you on a special diet? l i (ll) 1 C] YES 2 [:1 NO — SKIP Io quesIIon 2a 5. II “YES," is this am - : yes No Toloseweight?..........; ...................... :(IZIICI 2D Togainweight? ......................... : (13) 1:] 2|:] For diabetes? ............................ . ..... : (N) i [:I 2 [:1 For kidney failure? .............. . ................ i (‘5) I I: 2 C] For ulcers? ......................... . . . ........ i (16) IE] 2 [3 For diverticulitis? .................. . . . .......... . i (17) I [:1 2 [:I For allergies? .................................. i (‘8) I C] 2 C] For heart trouble? ............................... : (‘9) l [:1 2 Cl Forhighbloodpressure?.................:.........:(NIIEI 2D FEMALES ONLY — For pregancy? .................... : (2‘) l D 2 [:1 Foranyatherreason? ................ .............:(22)|D 3D If ”YES," give the reason I i I c. What kind of diet is it - : Is it - .' YES NO Lowtur? .............................. .......{(23).[:1 2):] Low protein? ....... ‘ ............................ : (24) i E] 2 [:1 High protein? ......................... . ........ i (25) i C] 2 C] Low salt? ...... . ............... . . . . ......... . i (26) i [j z [3 Low carbohydrate? ................ . . . . . . ...... . . . I: (27) i [j 2 C] Low sugar? ................................. . . : (23) i [j z E] Low calorie? ., ..................... . . ......... : (29) 1 C] 2 E] Low cholesterol. ........................ . ..... . . : (30) i E] 2 [:1 High calorie? .......................... . . . . . . . . : (3]) 11:] 2 [1 Vegetarian with animal by-produets (eggs, dairy, etc.)? ...... . i (32) I [:1 2 1:] Vegetarian without animal by-products? ................. : (33) I |:] 2 E] Ablanddiet? .................. ......... .: (34)IE] 2:! Some other type? ............................ . . . . I (35) t 2 C] Ii “YES,"describe the type oi am i E] i d. About how long have you been on this diet? II Specify how many weeks, months. OR years : (36-37) weeks I I (33-39) months I I : (40-0) years I v e s e I a I e. Was this diet prescribed by a doctor, a dietitian, or a nurse? : (42) ' [:JYES 2 ENG I 2a. Have you taken any of the following medicines or drugs within the PAST WEEK - Diuretics or pills for water loss? ...................... Other medicines to lose weight except Iluid pills? ........... Hormones? .................................... Steroids? ..................................... FEMALES — Birth control pills? ...................... Dilantin, used to treat epilepsy or seizures? .............. Medicine for lowering cholesterol? ..................... lNH (lsoniaxide, o drug used lor TB treatment and prophylaxis)? ............................... I | | l I : YES 22. Fungiform papillary hyper- I trophy of tongue . . . . . . . . I 23. Geographic tongue . . . . . . I 24. Fissures of tongue . . . . . . l __ _ _ 2 [30m _ _ l l I F' d' A. HEAD, EYES, EARS, ' I. ‘ C} N'" "‘55 NOSE, AND THROAT: I : 2 CI figdin s Continued : Yes l g 25. Serrations or swelling I : Yes oftongue..........l@iCl a. I E] 26. Scarlet beefy tongue . . . 3@ 1 D I. IE] 27. Magentatongue ......E@ 11:] | . l. 1:] 28.8leedinggums.......{. ilj l l I 29. D'ff a ' al I {. ilj inlflaur:;an:i<;rgtm........:@ :13 E@ 1:] 30. Swollen red papillae ...I. ll: §®1Cl 3I.Recession.........i@«(:1 :@ i E] 32. Naso-labial seborrhea . . i.1 [j i. i :1 33. Visible enlarged parotids :. I [j 1@ I E] 34. Bossingof Skull ......5 1D :.1 E] 35. Other —Deicribe ..... i 1 El l l l :@ . D : l I g. ‘ CI B. EXTERNAL EAR : :. ‘ E] (Except canal) I Right Left I l. N f' d‘ g _ ‘ 1.1m SlgletomCs. ......... E.1[j ilj :@ 1D 2. Findings — i C ' ' h 3 . . . . . . ' E@ 1 [j ontrnue wrt : _____ ti:— ______ 2—9— :? 1 E1 3. Operative scar ...... E. i C] ® 1 El l® l [:J I """""""""""" E@ II: 4. Other — Deicribe ..... i. I {j 1:] l | 1. . D l | _____________ I® ‘ E] : ————— Yes Yes :.1El 5.Piercedears ..... ....1 TE il:l l Sample number .0 . :1 | ,0 . :1 131 I c. ammo" CANAL ; Right Left E. NARES 2 Right Left L No findings — : I. No findings - : SKleD .......... :..D @lD SKleoF .......... {@.D @ID 2. Findings — i 2. Findings — : Continue with 3 . . . . . . E 2 E] z D Continue with 3 ...... E 2 E] 2 D I """"""""""" l" _______________ 3, Occluded - E 3. Obstruction : l ., Panially ......... :@ |Cl @ . Cl 0- Acutc ----------- 1" Cl @ ' D l a 5. Completely ...... . _ E z D 2 D 5. Chronic .......... E 2 E] 2 [:1 r ----------------- r- ----------------- ‘. Occluded by- 4. Other significant l I l C E@ D @ D findings — E e. erunien.........i I I l b. Other — Deslcn'be. . . . E 2 D 2 D e. Dewated septum . ' ' ' E”:_l;l____‘-E_ E h. Swollen turbinates . . . :. I [j l D I r‘ """"""""" E c. Chronic inflammation 3.1 [:1 l D 1 r -------------- 0. Dana ' Right Left ' ' N “If E d. Polyps .......... E'M—J-g" . o l ings — ‘ 5,“me ,,,,,,,, .. E..D @‘D «Other—Describe... E.i|:] .ID 2. Findings - i : Continuewith4......: 2D 2:] : I l 3. Not visible ...... . . . E a D 3 D F. NECK E )- ————————————————— l ' I. No f'nd‘n s — ' ' WWW :®'a ecu .......... min 5. Tiansparent ......... : z D 2 D 2 Findings : L _________________ - - I | Continue with 3 ...... I 2 D a. B l ‘ ............ ‘ ' u ‘m‘ ‘ :. ‘ D ' D 3. Adenopathy ......... 1.1 D 7. Retracled .......... l 2 D 2 U ' E _________________ ‘. Tracheal deviation . . . . E. l D 8. Calcium pluues . . . . . . E@ I D u D 5. Other - Describe ..... E. i C] _________________ I I -———-———-—————-— l 9. Red ........ . ..... E@ I [j l D : '0- 0"” d'm'm‘m‘ -- - E____‘P_______‘P__ c. ruvnouo EVALUATION—E . a Group 0 II. Fluid ............. E. l D I G " (VINO Cleseiilcflion) : 2 [B] 2:23: ; ----------------- 9 G 3 I2.$cars ........ E®lD .iC] 1: ”3 roup Ir ----------------- 2. omen THYROID g l :1 Findings '3. Perfumed : F'ND'NGS " : z D No findings — . . GO to H e.Vlithdischavge E. I D @ I C] E R L Both 5. Without dischuge . . . : z D 2 D 0. Tenderness ....... I I C] 2 D 3 D r ----------------- l .. . b.Nodule .......... ..‘|3 zuag H.0tnerhndings....... g®|l2l @q: . Describe 7 e.ls:lunus .......... E.i|:| (homer—Definite 1.1D l l I I : _______.____ Sample number I I i I I 132 H. CHEST EVALUATION — If findings, mark applicable box and continue with I. If no findings, SKIP to H6. j I '® I D Findings , 2 D No findings Yes I. Beading of ribs ................................. : ® I D 2. Follicular hyperkeratosis of upper back .................. i. I D 3. Wheezing on auscultation i 0. Diffuse ..................................... :@ ii: 5. Focal ...................................... E@ I D 4. Decreased breath sounds (diffuse) ..................... E® 1 D 5. Masses (Breast) ................................. ;® I [:1 Right I | z [3 Left I : 3 Cl Both 6. Auscultation ngn' E Abbsgm Brogihial Rules Rhonchi Wheeze sounds : ' ' ‘ ' . RigM chest : .IDNofindings-f Upperlobe 1D : 2D .iC] “Maia T F' (1' 2D mints Middlelobe @IDE 2D @ID ®1D®ID@|D i Loweriobe .iEJJ: 2D @‘D H‘D@'D‘D Left eh“! I Upperlobe @IDE :0 @ID @1D@1D@1D i L°*°"°°° ® ‘0! at: @ 'Cl va. '0. .g 7. Other chest findings @ I C] None. 2 D Findings Notes Sample number 133 134 I. HEART l. .P.M.l. (Age l8 and over) .......... 2. Interspace .................... 3. Midclavicular line ............... 4. Thrills ...................... o. Systolic .................... b. Diastolic ................... 5. Heart sounds a. lst heart sound ............... b. 2nd heart sound ............... 6. Murmurs ..................... a. Type ..................... 5. Location ('I) Apex ................... (2) Midprecordium ............. (3) Left base ................ (4) Right base ............... c. Origin (1) Mitral ................... (2) Rortic .................. (3) Tricuspid ................ (4) Pulmonic ................ (5) ASD .................... (6) vso .................... (7) Other ................... (8) Don't know ............... 7. Other cardiac or a. Edema ..................... b. Cyanosis ................... fl . Irregular pulse ............... fl. . Other — Describe ............. cardiovascular findings ........... ' :@ lDFelt z [:1 Not felt E @ 4 E] 5 [:l 6 1:] 7 [:| E 1:] At 2 C] Inside 3 :1 Outside I @ l [3 Absent 2 1:] Present E l [3 Base 2 E] Apex E @ I |:] Base 2 Cl Apex l i l E] Normal l Systolic murmur(s) | | I @ 1 E] Functional { 2 |:] Organic ' s C] Don't know I— _______________________ ' Grade E@ iDzD 3:14: EDGE r. _______________________ L® vmzmaaamsmsm L® vmzaamamsasm :. imzmamnmsflsfl 2 [:l Accentuated 5 ® 1 D Normal 2'|:| Accentuated '® 1|:]None-SKlPto7 3 [j Diminished 3 [j Diminished Diastolic murmur(s) ® I [:1 Functional 2 C] Organic 9 1:] Don't know Grade @imzmamamsmem .vmzaammsasm imzaamrmsmea l Systolic Diastolic i@ .3 2D 5@ 'D 2D :@ .5 2C] 1 1D 2 [:1 a 2:] .®'l:l 2|:l 1:1 2:1 [:1 Both 3:] 3D 3[II 3C] 3D 3C] 3E] z [:1 Yes — Continue with 70 Sample number F ORM HRA-IZ-3 (2-27-76) J. PULSE — ARTERIAL EVALUATION | | (Age l8 and over) : Sclerotic and l. Palpation : Normal Sclerotic Tortuous TOFIUOUS a. Right radial .................... i. I [j 2:] 3C] AC} | b. Right femoral ................... :. I C} 2|: 3[:] 4D | c. Right dorsalis pedis ............... 1. I |:| 2D 3:] ID d. Left radial ..................... :® I B 2g 31:] :[j | e. Left femoral .................... :@ 1:] 2 D 3 [:| 4 [:] I 5. Left dorsalis pedis ................ :. I [j 2 [:1 3 E] a E) l 2. Pulsations : Normal Diminished Bounding Absent , , I o. RIghtradIai .................... :@ I [j 21: 3B 4:] b. Right femoral ................... :@ I [:1 2 E] 3 [:] 4 D I :. Right dorsalis pedis .............. {(273) 1D 2 C} 3 D n [j , I d. Other — De§cnbe ................ i. I 1:] 2 [j 3 C] 4 D I I l e.Leftradia|.... ................ :@1D 2:] 3C] 4:] ' I 5. Left femoral .................... i I D 2 E] 3 [j 4 [j 9. Left dorsalis pedis ............... :@ I E] 21:] 3D 41:] I in Other — Desvcribe ................ l. I (:J 2 C] 3 [j ‘ :1 | I I K. ABDOMINAL EVALUATION ' _ I AND KIDNEY l. 'E] Flndlngs . , , l 2 D No if fIndIngs, mark appIIcabIe I . I box and continue with i. : fIndIngs if no findings, SKIP to L. I Yes I I/ X l. Heparomegaiy. . . ........ ;@ 11:] I \ l I Splenomegaly ............. l. I[:] . \' Iv, y . Uterine enlargement . . .- ..... E. IE} . Inguinal hernia ............ (29 I Z] /\I\\ I . Femoral hernia ............ :. 1:, . 1 2. 3 3 6 . Umbilical hernia ........... 5.1 E (4 .P0( belly ............... :.1|j . Mass(es) ................ E. I 1:] 7 (I) Area(s) ~ Enter number(s) . . i 288 _____ . ONOU‘IAB’N (2) Other findings — Degm’be . . :.1 [j 9. Surgical scars ............ i. 1D (l) Area(s) — Enter number(s) I . :. _____ (2) Other findings — Desvcribe . . i. l E] Sample number 10. CVA Tenderness ........... :. I [:1 135 i“: JUN JUN JUN 3:... EH: £UJamDm mDn «5.9mm: xfltemfl: ¢_U_® JD N , , JD N JD u JD u 305. . EU” 1H79mfln EH: EU.@£Un EH7®£Un ¢_H_.® JD ~ JD u JD... JD ~ noon. . mfl: KB, mfl: 2H: 18.6mm” Steam: ¢D_® JUN . . J_H_~ J_H_~ JmUN ~_V.:<. mDn amtemfl: Hyman mflf®mmm £HT®2UM zD—@ Dr. Em Dr. mm D... mm D.» am On Dc Dv Dc Dv D. D: De H: De _H_n an mm D.” mm D" D" an an . UN H: H: D" H: H: D" H: UN sufifigmuw D_®D.9D_9D.9D_®D_6D.®D_6,D.®D_®D.@D.@ Lari—3&0. col. 23.... En an an an H: D». Dr. Em Dm Dr. D¢ Do Dv Dc Dc D¢ Do D. De Dc o>o>:_. an an Do an an an mm am mm Dm G __~vw:,a_mrflw D~ H: EN EN fl: EN EN EN aw DN L35 a_6méa_®a_9 m_®m9a_®m_@a.@m.® H: mm mm D... D». an Dr. an an an Dc Du m: U: D< H: De, me D. Be an an mm D0 D.” an an mm D" an Gw>_o>c..ozv EN EN H: Um Du fl: EN EN Du UN Keying a.em_ea_®a_6 a.®a,ea,®m_®m.®a,e :..... Eué c3 Era :oJ Ema :3 £3: :3 28¢ JDN JUN JDN JEN JUN 6:3. mDm mD_emDn «fife mDm 1D_9mgn «D—emmn mflfe JD“ JUN JUN ._D~ 1H: 226. EM: «Wigwam mg_e mDm EMEQEUM £HT®£U~ EH79 JUN JUN JUN 1H: 1H: 82:25. mDn xU_@mDm EHTQ mam ¢D_6mgm EHTGEUM mfiu_6 .050 50:08 :0 £an m‘cwflwwmuI 52:8va szoSm Etc»... “uh” mZO_.r<._.mwu:z @3538 EB 09.5on I mmEvEn. flu N _ J S 2 Eva I 352.: 02 D. u . 6“ 5.23 .2... S as: 32.2 .J _ 136 I M. “C" 1. i [:1 No findings — SKlP to N I 2 C] Findings - Continue with l l I. Scoliosis ................ 1. l [:1 2. Kyphosis ................ 1.1:] 3. Lordosis ................. 1.1 [:1 4. Tenderness 1 a. Sciatic notch ............ 1.1 [:1 R 2 1:] L a [:1 Both b. Sacroiliac .............. :® 1:] R 2 [:1 L 3 1:] Both 1 . c. Other — Describe ......... 1® i [:1 1. l 5. Limitation of motion 1 a. Thoracic spine ........... 1. i C] b. Lumbar spine, right i lateral flexion ........... 1.1 1:] c. Lumbar spine. left ' lateral flexmn ........... 1w 1 [:1 :1. Full extension ........... l@ 1 [:1 1 V 6. Pain on motion ............. 1® 1 1:1 Negative 2 [3 Positive l_'"""Ee—&Tc'al_ """""""" 1 _____________________ 1 Severity of pain Thoracic Low back Diffuse Uncertain I (Mark one box) 7.Flexion .................. 1@o[jNone @113 .‘Cl @IE] .11: 1 i [:1 Doubtful | z [3 Minimal 1 3 1:1 Moderate 1. "193435191 ____________________ _ ______ _ ______ a. ‘ ........... ' Extension ..... 1.01:]None .IC}.i1:]‘I[:|.I[:1 1 I [:1 Doubtful 1 2 1:] Minimal 1 a C] Moderate 1 4 1:] Maximal 9.Right|atera|bending ..... ...1 .................. 1C1 i[:| w 11:1 @ 11:1 10. Left lateral bending ......... 1 .................. l[:1 11:1 ® 113 @ 11:1 H.Rightrotation ............. l .................. @ i1_‘_'] @113 @113 @113 l 12.Leftrotation .............. 1 .................. @113 ® 11:] @ilj .‘Cl N. STRAIGHT-LEG-RAISING l TEST 1 i l . . . 1. Right leg ................ 1.1 [:1 Negative 2 1:] Positive 2. Left leg ................. 1. i [:1 Negative 2 [:1 Positive 3. Increase — l a. 0n ankle (right leg) ........ 1. I [:1 Yes 2 [:1 No | . ' l ’ | ...... b Dorsif exion ( eft leg) 1. l :1 Yes 2 E] No 0. OTHER SYSTEMS .1 l [:1 No findings -— SKIP to P (Reticulo endotheliul, G.|., etc.) 2 D Findings _ Describe 7 Sample number FORM HRA-‘Z-3 (2-27-76) Pfl‘e 7 137 P. MUSCULOSK EL ETAL EVALUATION - IE] Findings R. SKIN EVALUATION ID Findings I i I 2 [3 No lf findings. mark applicable : z [:I No I I I I I I | I I I l | | | lf findings, mark applicable . , box and continue with I. findings box and continue with I. fIndIngs If no findings, SKlP to Q. Yes If no findings, SKIP to 5. Yes _. _a _ d | .......... I . Follicular hyperkeratosis. Bowe egs i. ‘CI arms I. 'E] 2. ............ l ‘ Knock knees :. ‘ D 2. Hyperpigmentation, hands : 3. Epiphysial enlargement, : and face .............. : I |:] WHSIS """""""""" : ‘D 3. Dry or scaling skin ....... :@ I [:l _ I 4' UM!" “9° 3 I. 4. Perifolliculosis ......... E. IE! Abduction of hips ......... I.409 I [j . . I (Ortolani's Maneuver) : 5. Petechiae - Des'cnbe ..... : I (:1 5. Other findings — Deicribe. . . . E. I C} E 6. Mosaic skin ............ I :@ El 7. Pellagrous dermatitis ..... :. I [:J 6 [I Q. NEUROLOGICAL . Ecchymoses — Degcribe. . . . EVALUATION @ I [:3 Findings lf findings, mark applicable 2 E} No | box and continue with l. findings 9' Edema """""""" :@ ‘ [:1 HM findings. SKIP to R- Yes 10. Other findings — Des‘cribe . . :.1 III 1. Ab t k ' k ......... ' sen neelers :@IC] i 2. Absent ankle jerks ........ :@ I {:1 : . . , ' S. EXAMINER'S SUBJECTIVE ' 3. POSItIVe ChVOStek Sign ..... :@ I {:1 IMPRESSION OF NUTRI- : 4. Apathy ................ i @ I :1 TIONAL STATUS ' I | . . I 5. Marked hyperirritability ..... :. IE} ‘- N°""a' "“""'°” --------- l. ‘ I3 6. Other findings _ Describe "‘i@ ‘ C] 2. Abnormal nutrition ....... I 2 [:1 | I l T. I. Obesity .............. :. ID | | i 2. No obesity ............ l 2 E] Notes Sample number 138 u. BLOOD PRESSURE; Cuffwidth l. Recumbent ...... :@ ‘ Cl Adu" @ I . 2. Sitting ........ : 1 [:1 0"” DAM. @ ___ . ___ Systolic Diastolic Examiner No. @ —-— @___ __ V. SUMMARY OF DIAGNOSTIC IMPRESSIONS r [:1 Normal; no abnormal findings 2 1:} Abwcrmal; significant findings noted below Severity Certainty ICDA code Min Mod. Sev. (0—9) a. :.vi:| 21:] 3[:| @_ @ ___.— I b. E 1:] 2D 3:] @_ ___...— c. §.l[j 2:] 3:] @_ ___._._ d- §.'D 2:1 3D 69— @ ___.— n .. E@im 2m 3C! @— ———— 4- §@'l:l 2D an (ID—— @ -———-— 9--—~ E.‘l:l 2:1 36 ®—— ___.— I h. €.i[j 2:] 3:] ® _ ___..— . i- i.‘l:l 2D 3C] ®_— ___.— i- §.'i:i 2:! 3E] (29— ___.._ k~ E.‘l:l 21:; 3:] @_. @ ____ i I. §@ID 2E3 3:] @_ @ ___.— l m. §.i[j 2E] 3D @_ ___._.. n- i.'D 2:) am ®—— ——-—-—- o. :.'l:l 2:] 3C] G)-— ® ___-— Physician Sample Number Name Number 139 07L FILL ITEMS I—9 ON PAGE 3 OF THE HOUSEHOLD QUESTIONNAIRE (HES-30) FOR ARMED FORCES HEAD OF FAMILY, LIVING AT HOME, HAVING ALSO, BE SURE TO INCLUDE HIS INCOME IN QUESTIONS 20, ZI, AND 22 ON PAGE 7 OF THE HES-30. ONE OR MORE SAMPLE PERSONS IN THE FAMILY. F0 RM H ES-G (9'26'77) U.S. DEPARTMENT OF COMMERCE BUREAU OF THE CENsus ACTING As COLLECTING AGENT FOR THE U.S. PUBLIC HEALTH SERVICE INTERVIEWER INFORMATION CARD BOOKLET H EALTH EXAMINATION SURVEY FORM HES-6 (ran-11) WI Explanation of the Health Examination Survey The basic purpose of the Health Examination Survey is to obtain a complete picture of the health and health needs of the Nation. In such a survey, data are collected by examining and testing a selected sample of persons. Such examinations and tests yield health information unobtainable through interviews or from medical records. The exami- nation can provide information not only about diagnosed conditions but also about undiagnosed conditions of which people are not aware. In addition, information about family nutrition and certain physical and physiological measurements such as height, weight, visual acuity,blood pressure and cholesterol can be obtained. Such data are essential for many purposes; only by knowing what is normal can the abnormal be defined. Data are compiled for use by Federal, State, and local health departments, medical schools, research organizations, and other groups or individuals. The Bureau of the Census is conducting the HES Survey for the U.S. Public Health Service because of the urgent need for up-to-date statistics on the health of the people. The survey is authorized by Title 42, United States Code,‘ Section 242k. The information collected is confidential and will be used only to prepare statistical summaries. Partici- pation in this survey is voluntary and there are no penalties for refusing to answer any question. However, your cooperation is extremely important in obtaining much needed information to insure the completeness and accuracy of the data. FORM HES-6 (9-26-77) CARD HM WHO IS TO BE INCLUDED AS A HOUSEHOLD MEMBER A. PERSONS STAYING IN SAMPLE UNIT AT TIME Include as member of household OF INTERVIEW Any person in unit, including members of family, lodgers, servants, visitors, etc. I. Ordinarily stay here all the time (sleep here) ......... 2. Here temporarily - no living quarters held for persons elsewhere . .* ......................... 3. Here temporarily - living quarters held for persons elsewhere .......................... In Armed Forces I. Stationed in this locality, usually sleep here . . . . . 2. Temporarily here on leave — stationed elsewhere ...... Students — Here attending school .................... Yes Yes No Yes Yes 3. ABSENT PERSONS WHO USUALLY LIVE HERE Inmates of specified institutions — Absent because inmate in a specified institution (see listing in Part C, Table A) regard- less of whether or not living quarters held for person here . . . Persons temporarily absent on vacation, in general hospital, etc. (including veterans’ facilities that are general hospitals)— Living quarters held here for person ................. ' Absent in connection with lab I. Living quarters held here for person — temporarily absent while “on the road” in connection with job (e.g.. traveling salesmen. railroad men. bus drivers) ............... 2. Living quarters held here and elsewhere for person but comes here infrequently (e.g., construction engineers) . . . 3. Living quarters held here at home for unmarried college student working away from home during summer school vacation ............................ In Armed Forces — Were members of this household at time of induction but currently stationed elsewhere ............ In School —- Away attending school ................... Seamen — Living quarters held here for person ........... No Yes Yes No Yes No No Yes C. EXCEPTIONS AND DOUBTFUL CASES Persons with two concurrent residences I. Regularly sleep greater part of week in another locality . . 2. Regularly sleep greater part of week here ............ Citizens of foreign countries temporarily in the United States I. Living on premises of an Embassy, Ministry, Legation, Chancellery, or Consulate ...................... 2. Not living on premises of an Embassy. Ministry, etc. — a. If livi_ng and studying here and no usual place of residence elsewhere in the United States .......... b. If living and working here and no usual place of residence elsewhere in the United States .......... c. If merely visiting or traveling in the United States . . . . Student nurses living at school ..................... No Yes No Yes Yes No No EXPLANATION CARD HM (Cut along broken lines) CARD A I; ” 1978 AGE VERIFICATION CHART Birthday In I978? Birthday In I978? Y . . ear of mm No AGE Yes Year of bIrth No AGE Yes I889 88 89 I934 43 44 I890 87 88 I935 42 43 I89I 86 87 I936 4| 42 I892 85 86 I937 40 4| I893 84 85 I938 39 40 I894 83 84 I939 38 39 I895 82 83 I940 37 38 I896 8| 82 I94I 36 37 I897 80 8| I942 35 36 I898 79 80 I943 34 35 I899 78 79 I944 33 34 I900 77 78 I945 32 33 I90| 76 77 I946 3| 32 I902 75 76 I947 30 3| I903 74 75 I948 29 30 I904 73 74 I949 28 29 I905 72 73 I950 27 28 I906 7| 72 |95I 26 27 I907 70 7| I952 25 26 I908 69 70 I953 24 25 I909 68 69 I954 23 24 I910 67 68 I955 22 23 I9I I 66 67 I956 2| 22 I9I2 65 66 I957 20 2| I9I3 64 65 I958 I9 20 I9I4 63 64 I959 I8 I9 I9I5 62 63 I960 I7 I8 I9|6 6| 62 I96I I6 I7 I9I7 60 6| I962 I5 I6 I9I8 59 60 I963 I4 I5 |9|9 58 59 I964 I3 I4 I920 57 58 I965 l2 I3 l92l 56 57 I966 I I I2 I922 55 56 I967 I0 I I I923 54 55 I968 9 l0 I924 53 54 I969 8 9 I925 52 53 I970 7 8 I926 51 52 I97I 6 7 I927 50 5| I972 5 6 I928 49 50 I973 4 5 I929 48 49 I974 3 4 I930 47 48 I975 2 3 I93I 46 47 I976 I 2 I932 45 46 I977 Und. | I I933 44 45 I978 NA Und. I I II I8 25 I6 23 30 5 I3 27 I5 22 @ JANUARY T V T 3 4 5 9 10 II 12 I7 I8 I9 24 25 26 31 FEBRUARY T I 14 21 28 T 4 II 18 25 T 6 I3 20 27 C) Holidays NOTE: Appropriate age verification charts and calendars were used for each year the survey was in progress. I T I 2 a o 15 I6 22 23 APRIL W T 5 6 I2 I] I9 20 26 27 HAY I T 3 4 10 II I7 18 24 25 3I JUNE V T I 7 8 Id 15 21 22 28 29 1978 II 25 9 I0 24 I3 20 27 10 I7 31 M 3 IO 17 24 31 21 28 JULY T W T @56 II 12 I3 18 I9 20 25 26 27 AUGUST T W T I 2 3 8 9 ID 15 I6 17 22 23 24 29 30 31 SEPTEMBER T W T @567 18 25 M 2 12 13 14 I9 20 21 26 27 28 OCTOBER T W T 3 A 5 @w II I2 I7 18 I9 20 I6 23 30 6 I3 20 2I 22® 27 I II II 24 25 26 3| NOVEIBER T H T I 2 7 .8 9 14 I5 16 28 29 30 DECEIBER T W T 5 6 7 12 13 14 I9 20 21 ® 26 27 25 II 18 25 15 22 IS 22 29 16 23 CARD A - 1978 1978 CALENDAR —— CARD C CHART FOR CONVERTING NUMBER OF CIGARETTES SMOKED PER WEEK TO I I I I I l o o o o o o o 0 NUMBER OF CIGARETTES SMOKED PER DAY { °° \' °‘ ”1 A w N _ ' O 'U 3 Z X n n n I g c m m m g 3: cm 2 I (9 £2 E. >_<. 5- N n c 3 I ‘ 3 s 8 a = a 3 c: Number per week Number per day I é” JO 3 8 3 0 > 5' I m -- ' In . 3 V2 pack ............. I ___________ : 3- g :3: g 9., 3' q -' n I pack ............. 2 "' 8 m 0 ONVO 8 g “/2 packs ............ 4 3 Guys 3 i 2 packs ............ 5 2 2V2 packs ............ 7 3 packs ............ 8 5’ z 3'/2 packs ............ l0 9, 5:: :r m S 4 packs ............ ll ; n_ 4% packs ............ I2 E 9 n U '3' g 5 packs ............ l4 8 O _ _ _ o 3 U H N —- C) O o I carton ............ 28 : 23 " O 2 x u. 3? 5 ‘2 — 9 > 3 2 E 6‘ 2 8 3' 3 § NOTE: If respondent answers in terms of a month, I g 3' 3 3' 2V _:T " m divide the answer by 4 to obtaIn an estimate for a m 9 3" 2 g 2 m2" 3 week and then make the converSIon to number per ‘3 '0 D 'U — ,‘3 a?) 3 day based on the above chart. 3; at 3: 8- E- _E‘; 5% E 5 3 ,1: 3 o 5".8 ‘o 0' ‘ "I" .7. 2 > 71‘” EXAMPLE Ben—n— ), 2." a E ' m 3 — 9 = 3 Respondent states he smokes a carton a month: 3 g 93 £ 3 "’ o 9.” a 2 0 I. | cartonzlo packs g 9 Z 5‘ Q m 3 3 2. l0+4=2V1 packs per week 5. 3 m 3. 2V2 packs per week=7 cigarettes per day FORM HES-6 (9-26-77’ 8H til CARD I Which of these income groups represents your total combined family income for the PAST 12 MONTHS? Under $1,000 (including loss) . . Group A $ 1,000 — $ 1,999 .......... Group B $ 2,000 — $ 2,999 .......... Group C $ 3,000 — $ 3,999 .......... Group D $ 4,000 -$ 4,999 .......... Group E $ 5,000 - $ 5,999 .......... Group F 3 6,000 — $ 6,999 .......... Group G $ 7,000 -$ 9,999 .......... Group H $10,000 — $14,999. . L ....... GroupI $15,000 - $19,999 .......... Group J $20,000 — $24,999 .......... Group K $25,000 and over. . . . . .: ..... Group L FORM HES-6 (9'26-77) TARJETA I — INGRESOS Hoga el fovor de mirar a as": Iorieto — £Cué| de estos grupos representa el total combinodo de Ios ingresos de su fomilio duronte Ios riltimos 12 meses - esto es, el suyo, mcis el de su — — etc.? Incluyo ingresos de todas Ios fuentes roles como iornoles, solarios, beneficios de seguro social 0 retiro, ayuda economico por parte de fomiiiares o parientes, olquiler de propiedades, erce’tero. Menos de $I,000 (incluyendo pérdidas) . . Grupo A $ l,000 — S |.999 ............... 'Grupo B 5 2.000 — 5 2,999 ............... Grupo C 5 3,000 — 5 3,999 ............... Grupo D 5 4.000 — S 4,999 ............... Grupo E 5 5,000 — 3 5.999 ............... Grupo F 5 6.000 — 5 6,999 ............... Grupo G 5 7,000 — 5 9,999 ............... Grupo H $l0.000 — $|4,999 ............... Grupo I $i5,000 —- $|9,999 ................ Grupo J 520.000 — $24,999 ............... Grupo K $25,000 0 més .................. Grupo L CARDI CARD I (Spanish) Vital and Health Statistics series descriptions U12. BERKELEY LIBRARIES lllll'lllflllllllllflli COEIEDSQEH SERIES 1. Programs and Collection Procedures—Reports describing long-term care, ambulatory care, hospital care, and family the general programs of the National Center for Health planning services. Statistics and its offices and divisions and the data col- SERIES 14. Data on Health Resources: Manpower and Facilities.— Iectlon methods used. They also include definitions and Statistics on the numbers, geographic distribution, and other material necessary for understanding the data. characteristics of health resources including physicians, SERIES 2. Data Evaluation and Methods Research—Studies of new dentists, nurses, other health occupations, hospitals, statistical methodology including experimental tests of nursing homes, and outpatient facilities. new survey methods, studies 9f V'ta' statistics collection SERIES 15. Data From Special Surveys.—Statistics on health and methods, new analytical techniques,obiective evaluations health-related topics collected in special surveys that of reliability of collected data, and contributions to sta- . . tistical theory. are .not a part of the continuing data systems of the National Center for Health Statistics. SERIES 3' Analytical and Epidemiological Studies—Reports pre- SERIES 20. Data on Mortality.—Various statistics on mortality other senting analytical or interpretive studies based on Vital . . . . . _ than as included in regular annual or monthly reports. and health statistics, carrying the analy5is further than . . . . Specnal analyses by cause of death, age, and other demo- the exposnory types of reports in the other series. . . . . . graphic variables; geographic and time series analyses; SERIES 4~ Documents 300' Committee Reports—Final FGDOFtS of and statistics on characteristics of deaths not available major committees concerned with vital and health sta- from the vital records based on sample surveys of those tistics and documents such as recommended model vital records. registration laws and reVised birth and death certificates. SERIES 21' Data on Natality, Marriage, and Divorce.—Various sta- SERIES 10. Data From the National Health Interview Survey.—Statis- tistics on natality, marriage, and divorce other than as tics on illness, accidental injuries, disability, use of hos- included in regular annual or monthly reports. Special pital, medical, dental, and other services, and other analyses by demographic variables; geographic and time health-related topics, all based on data collected in the series analyses; studies of fertility; and statistics on continuing national householdinterview survey. characteristics of births not available from the vital SERIES 11. Data From the National Health Examination Survey and records based on sample surveys Of those records. the National Health and Nutrition Examination Survey.— SERIES 22. Data From the National Mortality and Natality Surveys.— Data from direct examination, testing, and measurement Discontinued in 1975. Reports from these sample surveys of national samples of the civilian noninstitutionalized based on vital records are included in Series 20 and 21, population provide the basis for (1) estimates of the respectively. medically defined prevalence 0f specific diseases in the SERIES 23. Data From the National Survey of Family Growth.— United States and the distributions Of the population Statistics on fertility, family formation and dissolution, With respect to physical, physiological, and psycho- family planning, and related maternal and infant health logical characteristics and (2) analysis of relationships topics derived from a periodic survey of a nationwide among the various measurements without reference to probability sample of ever-married women 1544 years an explicit finite universe of persons. of age. SERIES 12. Data. From-the Institutionalized Population Surveys.—Dis- For a list of titles of reports published in these series,.write to: continued in 1975. Reports from these surveys are in- cluded in Series 13. Scientific and Technical Information Branch SERIES 13. Data on Health Resources Utilization.—Statistics on the National Center for Health Statistics utilization of health manpower and facilities providing Public Health Service Hyattsville, Md. 20782 US. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Office of Health Research, Statistics, and Technology National Center for Health Statistics 3700 East~West Highway Hyattsville, Maryland 20782 OFFICIAL BUSINESS PENALTY FOR PRIVATE USE, $300 from the Office of Health Research, Statistics, and Technology DHHS Publication No. (PHS) 81-1317, Series 1, No. 15 POSTAGE AND FEES PAID US. DEPARTMENT OF HHS HHS 396 Third Class I 51:11 for a listing of publications in the VITAL AND HEALTH STATISTICS series call 301 -436-NCHS