ANNUAL FOLLOW-UP RESPONSE CARDS
(Version Date: 02/15/2001)
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001
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RESPONSE CARD A
NONE OR FEWER THAN ONE A WEEK
1 PER WEEK
2 PER WEEK
3-4 PER WEEK
5-6 PER WEEK
7 OR MORE PER WEEK
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION B27b-B27d
RESPONSE CARD B
AFTER A FALL FROM A HEIGHT ABOVE THE GROUND
GREATER THAN SIX INCHES
IN A MOTOR VEHICLE ACCIDENT
WHILE MOVING FAST, LIKE RUNNING, BICYCLING, OR
SKATING
WHILE PLAYING SPORTS
BECAUSE SOMETHING HEAVY FELL ON YOU OR STRUCK
YOU
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION B29b
RESPONSE CARD C
MEDICAL DOCTOR (MD) ................................................. 1
DOCTOR OF OSTEOPATHY (DO) ................................... 2
CHIROPRACTOR (DC) ..................................................... 3
REGISTERED NURSE (RN) ............................................. 4
NURSE PRACTITIONER (NP) .......................................... 5
PHYSICIAN ASSISTANT (PA) .......................................... 6
OTHER (SPECIFY) ........................................................... 7
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 1QUESTION B39
RESPONSE CARD D
BECOME FARTHER APART ............................................ 1
BECOME CLOSER TOGETHER ...................................... 2
OCCURRED AT MORE VARIABLE
INTERVALS ....................................................................... 3
STAYED THE SAME ......................................................... 4
BECOME MORE REGULAR ............................................ 5
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C4
RESPONSE CARD E
LIVE BIRTH ....................................................................... 1
STILL BIRTH ..................................................................... 2
MISCARRIAGE ................................................................. 3
ABORTION ........................................................................ 4
TUBAL/ECTOPIC PREGNANCY ...................................... 5
STILL PREGNANT ............................................................ 6
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C6a
RESPONSE CARD F
0 1 2 3 4 5 6 7 8 9 10
WORST BEST
POSSIBLE POSSIBLE
QUALITY QUALITY
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C7
RESPONSE CARD G
NONE OF THE TIME ......................................................... 1
A LITTLE OF THE TIME ................................................... 2
SOME OF THE TIME ........................................................ 3
MOST OF THE TIME ......................................................... 4
ALL OF THE TIME ............................................................ 5
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C8
RESPONSE CARD H
NEVER .............................................................................. 1
ALMOST NEVER .............................................................. 2
SOMETIMES ..................................................................... 3
FAIRLY OFTEN ................................................................. 4
VERY OFTEN .................................................................... 5
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C9
RESPONSE CARD I
RARELY OR NONE OF THE TIME
(LESS THAN 1 DAY) ......................................................... 1
SOME OR A LITTLE OF THE TIME
(1-2 DAYS)......................................................................... 2
OCCASIONALLY OR A MODERATE AMOUNT
OF THE TIME (3-4 DAYS) ................................................. 3
MOST OR ALL OF THE TIME (5-7 DAYS) ....................... 4
ANNUAL FOLLOW-UP INTERVIEW
02/15/2001 QUESTION C10