Health Survey (English)

The date is recorded as [TODAY]  and the start time is recorded as [STTIME].
Q1.	Subject ID:	__ __ __
Q2.	SITE:  (Choose one)	0	A
	1	B
Q3.	Enter Visit Code:  (Choose one)	1	Baseline
	2	Followup

Demographics
Welcome to our Health Study.  Thank you for participating!
DEM1.	What is your gender?	1	Male
	2	Female
DEM2.	How old are you?	__ __	Years old
DEM3.	What is your current marital or partnership status?  (Choose one)
	1	Legally married
	2	Never married
	3	Divorced
	4	Widowed
	5	Domestic partnership
	6	Other
	8	Refuse to Answer
If DEM3 is not equal to 6, then skip to DEM5.
DEM4.	Please specify other marital or partnership status:
	__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
DEM5.	Which of the following best describe your race?  (Encourage the respondetn)  (Check all that apply)
	__	White
	__	Black or African American
	__	Asian
	__	Native Hawaiian or Pacific Islander
	__	American Indian or Alaska Native
	__	Other
	__	Don't Know
	__	Refuse to Answer
If DEM5F is not equal to 1, then skip to DEM6.
DEM5_o.	Please specify other race:	__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
DEM6.	What is your date of birth?	__ __ / __ __ / __ __ __ __	mm / dd / yyyy

Health
The next set of questions will ask about your health.
HLT1.	In the past year, has a health care provider recommended that you receive a flu vaccine?
	1	Yes
	0	No
	7	Don't Know
	8	Refuse to Answer
	9	Not Applicable
HLT2.	Using the line as a guide, how would you rate your current state of health? Pick any number between 1 and 10.
	01	Worst possible health
	02
	03
	04
	05
	06
	07
	08
	09
	10	Best possible health
	98	Refuse to Answer
HLT3.	Using any number from 1 to 10, where 1 is the worst medical care possible and 10 is the best medical care possible, what number would you use to rate the medical care you received in the past 12 months?  (Please select the number on the line)
	01	Worst Possible Care
	02
	03
	04
	05	Moderate Care
	06
	07
	08
	09
	10	Best Possible Care
	98	Refuse to Answer
	99	Not Applicable
HLT4.	How long has it been since your last medical appointment?
	__ __ __ __ __	YEARS
	__ __ __ __ __	MONTHS
	__ __ __ __ __	DAYS
	99997	Don't Know (Days)
	99998	Refuse to Answer (Days)
	99999	Not Applicable (Days)
HLT5.	In the last 2 weeks, how much were you distressed by:

Nervousness or shakiness inside  (Choose one)	0	Not at all
	1	A little bit
	2	Moderately
	3	Quite a bit
	4	Extremely
	8	Refuse to Answer
HLT6.	In the last 2 weeks, how much were you distressed by:

Faintness  (Choose one)	0	Not at all
	1	A little bit
	2	Moderately
	3	Quite a bit
	4	Extremely
	8	Refuse to Answer
HLT7.	What time do you usually wake up?	__ __ : __ __  [ __ ]	hh : mm   [ 1=AM, 2=PM ]
	98	Refuse to Answer (Hour)
HLT8.	What time do you usually go to sleep?	__ __ : __ __	hh : mm
	98	Refuse to Answer (Hour)

Activities
The next set of questions will ask about recreational activities.
ACT1.	Please rank your top 3 favorite recreational activities:	__ __	Eating out
	__ __	Movies or theatre
	__ __	Dancing
	__ __	Hiking
	__ __	Exercising at the gym
	__ __	Running
	__ __	Playing sports
	__ __	Watching sports
	__ __	Other activity
	97	Don't Know
	98	Refuse to Answer
If ACT1I is equal to 0 or ACT1 is equal to "Don't Know" or ACT1 is equal to "Refuse to Answer", then skip to ACT3.
ACT2.	Describe your other favorite activity:
	__ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
ACT3.	In the last 30 days, that is since [PAST30D], how many times have you gone to the movies?
	__ __
	97	Don't Know
	98	Refuse to Answer
If ACT3 is equal to 0 or ACT3 is equal to "Refuse to Answer" or ACT3 is equal to "Don't Know", then skip to instruction before TOB1.
ACT4.	Of the [Response to ACT3] times you went to the movies, how many times did you watch in 3D?
	__ __
	97	Don't Know
	98	Refuse to Answer
	99	Not Applicable
If ACT4 is greater than ACT3 then Number of times you saw a 3D movie cannot be greater than the number of movies you saw.  Please review your responses. and skip to ACT4.

Tobacco Use
The next set of questions will ask about tobacco use.
TOB1.	Have you ever smoked a cigarette?	1	Yes
	0	No
	7	Don't Know
	8	Refuse to Answer
If TOB1 is not equal to 1, then skip to TOB8.
TOB2.	How old were you the first time you smoked a cigarette?	__ __
	97	Don't Know
	98	Refuse to Answer
TOB3.	During the past 7 days, how many cigarettes did you smoke?
	__ __ __
	997	Don't Know
	998	Refuse to Answer
If TOB3 is not less than 1 then skip to TOB4
If not, then skip to TOB8.
TOB4.	How many cigarettes did you smoke yesterday?	__ __ __
	997	Don't Know
	998	Refuse to Answer
If TOB4 is greater than TOB3 then You reported smoking more cigarettes yesterday (&[CIG_YES]) than in the past 7 days (&[CIG_WEEK]).  Please review your responses. and skip to TOB3.
TOB5.	When you smoke, how soon after you wake up do you have your first cigarette? Would you say….  (Choose one)
	1	Within 5 minutes
	2	6-30 minutes
	3	31-60 minutes
	4	After 60 minutes
	7	Don't Know
	8	Refuse to Answer
TOB6.	Have you ever tried to quit smoking?	1	Yes
	0	No
	7	Don't Know
	8	Refuse to Answer
TOB7.	Do you want to quit smoking cigarettes?	1	Yes
	0	No
	7	Don't Know
	8	Refuse to Answer
TOB8.	Do you have any additional comments?  Select "Not Applicable" if none.
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You have completed the survey.  Thank you!