Site
ID
What is your current marital status
Housing type
Currently working at paying job
Have you retired from work/job
Household composition summary
Member of club/organization/church group
How often do you go to religious meeting
How many relatives do you feel close to(
How many close friends do you talk to
What is the data (today)
What day of the week is it
President of the U.S. (now)
President of the U.S. (previous)
Mother's maiden name
Telephone number
Subtract 3 from 20
Need help - walk in doors
Walk help - from person or equipment
Need help - bathing
Bathing help - from person or equipment
Need help - personal grooming
Grooming help - from person or equipment
Need help - dressing
Dressing help - from person or equipment
Need help - eating
Eating help - from person or equipment
Need help - getting from bed to chair
From bed to chair - from person or equip
Need help - using the toilet
Toilet help - from person or equipment
Able to do heavy work around the house
Able to walk up and down stairs to 2nd f
Able to walk 1/2 mile w/o help
Difficulty pulling/pushing large objects
Difficulty stooping/crouching/kneeling
Difficulty reaching/extending arms above
Difficulty writing or handling small obj
W/wo hear aid-understand speech w/o seei
Do you ear eyeglasses/contact lenses
When wearing glass/len can read ordinary
Difficulty holding urine
Health compared to others in age group
Dr ever told you had heart attack
Dr ever told you had stroke
Dr ever told you had cancer
Dr ever told you had diabetes
Currently taking insulin
Dr ever told you had hip fracture
Dr ever told you had any other fractures
Ever had any pain in chest
Ever had any pressure in chest
Get pain when walking uphill or hurring
Get pain when walking at ordinary pace
What do you do if you get this pain
Standing still, what happens to pain
How soon is the pain relieved
Where was pain (sternum-middle or upper)
Sternum (lower)
Left anterior chest
Left arm
Did you feel it anywhere else
Ever had severe pain front chest-1/2 hr
Did you see a doctor because of this pai
How many of these attacks have you had
What is your weight (pounds)(EB rounded
Since last spoke-gained/lost > 10 pounds
First blood pressure reading-Systolic
First blood pressure reading-Diastolic
Second blood pressure reading-Systolic
Second blood pressure reading-Diastolic
How often have trouble falling asleep
How often have trouble waking up during
How often trouble waking up too early
How often get so sleepy in day/eve need
How often feel really rested when wake u
Do you smoke cigarettes (regularly) now
Number cigarettes smoked per day (curren
Have you had any beer or ale during the
Have you had any beer or ale in the past
Over the (past/last) month how often hav
When you did have beer/ale how many cans
Have you had any wine during the past ye
Have you had any wine in the past month
Over the (past/last) month, how often ha
When you did have wine (past mo) how man
Have you had any liquor in past year
Have you had any liquor in the past mont
OTHLQRN
How many drinks did you have - past mont
Now taking digitalis,Digoxin,Lanoxin,or
How many times been hospitalized since l
Have you been (a patient) in nursing hom
How long did you stay in the nursing hom
Have you lost close relative (other than
Have you lost close friend in the past y
PERSINTV
Inverview status
EB-Felt everything was an effort
EB-My sleep was restless
EB-Felt depressed
EB-Felt happy
EB-Felt lonely
EB-People were unfriendly
EB-I enjoyed life
EB-Felt sad
EB-I felt people disliked me
EB-I could not get going
Iowa-I did not feel like eating
Iowa-I felt depressed
Iowa-Felt that everything was an effort
Iowa-My sleep was restless
Iowa-I was happy
Iowa-Felt lonely
Iowa-People were unfriendly
Iowa-I enjoyed life
Iowa-Felt sad
Iowa-I felt people disliked me
Iowa-I could not get going
Iowa-I lacked companionship
Iowa-Felt nervous, tense, and jittery
Iowa-Felt calm and relaxed
Iowa-Felt left out
Iowa-I was worried
Iowa-Felt cross and cranky
Iowa-Felt secure and content
Iowa-There were people I could talk to
Iowa-Felt that I was part of a group of
NH-Felt bothered
NH-Did not feel like eating
NH-Felt blue
NH-Felt just as good as other people
NH-Trouble concentrating
NH-Felt depressed
NH-Felt everything was an effort
NH-Felt hopeful about the future
NH-I thought my life had been a failure
NH-Felt fearful
NH-My sleep was restless
NH-I was happy
NH-Talked less than usual
NH-Felt lonely
NH-People were unfriendly
NH-Enjoyed life
NH-I had crying spells
NH-Felt sad
NH-Felt that people disliked me