Table of Contents
Health Status
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Would you say that in general your health is: Excellent, Very good, Good, Fair, or Poor? |
Healthy Days ? Health-Related Quality of Life
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Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good? |
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Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good? |
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During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as self-care, work, or recreation? |
Health Care Access
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Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare? |
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Do you have one person you think of as your personal doctor or health care provider? |
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Was there a time in the past 12 months when you needed to see a doctor, but could not because of the cost? |
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About how long has it been since you last visited a doctor for a routine checkup? |
Exercise
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During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise? |
Diabetes
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Have you EVER been told by a doctor that you have diabetes? |
Hypertension Awareness
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Have you EVER been told by a doctor, nurse, or other health professional that you have high blood pressure? |
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Are you currently taking medicine for your high blood pressure? |
Cholesterol Awareness
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Blood cholesterol is a fatty substance found in the blood. Have you EVER had your blood cholesterol checked? |
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About how long has it been since you last had your blood cholesterol checked? |
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Have you EVER been told by a doctor, nurse, or other health professional that your blood cholesterol is high? |
Cardiovascular Disease Prevalence
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Ever told you had a heart attack, also called a myocardial infarction? |
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Ever told you had angina or coronary heart disease? |
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Ever told you had a stroke? |
Asthma
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Have you EVER been told by a doctor, nurse, or other health professional that you had asthma? |
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Do you still have asthma? |
Immunization
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A flu shot is an influenza vaccine injected in your arm. During the past 12 months, have you had a flu shot? |
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During the past 12 months, have you had a flu vaccine that was sprayed in your nose? |
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A pneumonia shot or pneumococcal vaccine is usually given only once or twice in a person's lifetime and is different from the flu shot. Have you ever had a pneumonia shot? |
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During what month and year did you receive the most recent flu vaccination? |
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Where did you go to get your most recent flu shot? |
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What is the MAIN reason you have NOT received a flu vaccination for this current flu season? |
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Did you get a flu vaccination during the 'last flu season' in other words during the months of September 2003 throogh March 2004? |
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Has a doctor, nurse, or other health professional ever said that you have any of the following health problems? |
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Do you still have this/any of these problems? |
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Do you currently work in a health care facility, such as a medical clinic, hospital, or nursing home? |
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Do you have direct face-to-face or hands-on contact with patients as a part of your routine work? |
Tobacco Use
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Have you smoked at least 100 cigarettes in your entire life? |
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Do you now smoke cigarettes everyday, some days, or not at all? |
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During the past 12 months, have you stopped smoking for one day or longer because you were trying to quit smoking? |
Alcohol Consumption
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During the past 30 days, have you had at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor? |
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During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage? |
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During the past 30 days, on the days when you drank, about how many drinks did you drink on the average? |
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Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion? |
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During the past 30 days, what is the largest number of drinks you had on any occasion? |
Demographics
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What is your age? |
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Are you Hispanic or Latino? |
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Which one or more of the following would you say is your race ? Would you say: White, Black or African American |
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Are you: Married, Divorced, Widowed, Separated, Never married, or a member of an unmarried couple? |
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What is the highest grade or year of school you completed? |
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Are you currently: |
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What is your annual household income? |
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COUNTY |
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Do you have more than one telephone number in your household? |
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How many of these phone numbers are residential numbers? |
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During the past 12 months, has your household been without telephone service for 1 week or more? |
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What is your gender? |
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To your knowledge, are you now pregnant? |
Veteran?s Status
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Have you ever served on active duty in the United States Armed Forces, either in the regular military or in a National Guard or military reserve unit? |
Disability
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Are you limited in any way in any activities because of physical, mental, or emotional problems? |
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Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone? |
Arthritis Burden
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During the past 30 days, have you had symptoms of pain, aching, or stiffness in or around a joint? |
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Did your joint symptoms FIRST begin more than 3 months ago? |
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Have you EVER seen a doctor or other health professional for these joint symptoms? |
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Have you ever been told by a doctor or other health professional that you have some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia? |
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Are you now limited in any way in any of your usual activities because of arthritis or joint symptoms? |
Fruits and Vegetables
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How often do you drink fruit juices such as orange, grapefruit, or tomato? |
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Not counting juice, how often do you eat fruit? |
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How often do you eat green salad? |
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How often do you eat potatoes not including french fries, fried potatoes, or potato chips? |
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How often do you eat carrots? |
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Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat? |
Physical Activity
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When you are at work, which of the following best describes what you do? |
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Now, thinking about the moderate activities you do in a usual week, do you do moderate activities for at least 10 minutes at a time ? |
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How many days per week do you do these moderate activities for at least 10 minutes at a time? |
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On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities? |
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Now thinking about the vigorous physical activities do you do vigorous activities for at least 10 minutes at a time? |
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How many days per week do you do these vigorous activities for at least 10 minutes at a time? |
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On days when you do vigorous activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities? |
HIV/AIDS
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Have you ever been tested for HIV? |
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Not including blood donations, in what month and year was your last HIV test? |
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Where did you have your last HIV test - at a private doctor or HMO office, at a counseling and testing site, at a hospital, at a clinic, in a jail or prison, at home, or somewhere else? |
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Please tell me if any of the situations apply to you: You have used intravenous drugs, been treated for a sexually transmitted or venereal disease, given or received money or drugs in exchange for sex, had anal sex without a condom in the past year. |
Emotional Support and Life Satisfaction
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How often do you get the social and emotional support you need? |
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In general, how satisfied are you with your life? |
Heart Attack and Stroke
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Do you think pain or discomfort in the jaw, neck, or back are symptoms of a heart attack? |
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Do you think feeling weak, lightheaded, or faint are symptoms of a heart attack? |
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Do you think chest pain or discomfort are symptoms of a heart attack? |
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Do you think sudden trouble seeing in one or both eyes is a symptom of a heart attack? |
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Do you think pain or discomfort in the arms or shoulder are symptoms of a heart attack? |
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Do you think shortness of breath is a symptom of a heart attack? |
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Do you think sudden confusion or trouble speaking are symptoms of a stroke? |
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Do you think sudden numbness or weakness of face, arm or leg, especially on one side, are symptoms of a stroke? |
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Do you think sudden trouble seeing in one or both eyes is a symptom of a stroke? |
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Do you think sudden chest pain or discomfort are symptoms of a stroke? |
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Do you think sudden trouble walking, dizziness, or loss of balance are symptoms of a stroke? |
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Do you think severe headaches with no known cause are symptoms of a stroke? |
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If you thought someone was having a heart attack or stroke, what is the first thing you would do? |
Adult Asthma History
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During the past 12 months, have you had an episode of asthma or an asthma attack? |
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During the past 30 days, how often did you have any symptoms of asthma? |
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During the past 30 days, how many days did symptoms of asthma make it difficult for you to stay asleep ? |
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During the past 30 days, how many days did you take a prescription asthma medication to PREVENT an asthma attack from occurring? |
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During the past 30 days how often did you use a prescription asthma inhaler DURING AN ASTHMA ATTACK to stop it? |
Arthritis Management
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Thinking about your arthritis or joint symptoms, which of the following best describes you TODAY? |
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Has a doctor or other health professional EVER suggested losing weight to help your arthritis or joint symptoms? |
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Has a doctor or other health professional ever suggested physical activity or exercise to help your arthritis or joint symptoms? |
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Have you ever taken an educational course or class to teach you how to manage problems related to your arthritis or joint symptoms? |
Sexual Violence
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In the past 12 months, has anyone exposed you to unwanted sexual situations that did not involve physical touching? |
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In the past 12 months, has anyone touched sexual parts of your body after you said or showed that you didn't want them to or without your consent? |
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In the past 12 months, has anyone ATTEMPTED to have sex with you after you said or showed that you didn't want to or without your consent, BUT SEX DID NOT OCCUR? |
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In the past 12 months, has anyone HAD SEX with you after you said or showed that you didn't want to or without your consent? |
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At the time of the most recent incident, what was your relationship to the person who [had sex-or attempted to have sex] with you after you said or showed that you didn't want to or without your consent? |
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Was the person who did this male or female? |
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Has anyone EVER ATTEMPTED to have sex with you after you said or showed that you didn't want to or without your consent, BUT SEX DID NOT OCCUR? |
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Has anyone EVER had sex with you after you said or showed that you didn't want them to or without your consent? |
Intimate Partner Violence
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Has an intimate partner EVER THREATENED you with physical violence? This includes threatening to hit, slap, push, kick, or physically hurt you in any way. |
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Has an intimate partner EVER hit, slapped, pushed, kicked, or physically hurt you in any way? |
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Has an intimate partner EVER ATTEMPTED physical violence against you? |
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Have you EVER experienced any unwanted sex by a current or former intimate partner? |
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In the past 12 months, have you experienced any physical violence or had unwanted sex with an intimate partner? |
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In the past 12 months, have you had any injuries, such as bruises, cuts, scrapes, black eyes, vaginal or anal tears, or broken bones, as a result of this physical violence or unwanted sex? |
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At the time of the most recent incident, what was your relationship to the intimate partner who was physically violent or had unwanted sex with you? |
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Current Smoker. |
The data herein only reflects Montgomery county Missouri
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