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PROPOSED 2006 BRFSS QUESTIONNAIRE MODULES (NON CDC CORE)
Suicide 2
Residential Fire 3
Sexual Violence 4
Intimate Partner Violence 5
Anxiety and Depression Module 7
Fruits and Vegetables 9
Physical Activity 9
Secondhand Smoke Policy 10
Smoking Cessation 11
Follow-up to Second-Hand Smoking Policy: 12
Follow-up to Smoking cessation: 13
Adult Asthma History 13
Random Child Selection 15
Childhood Asthma Prevalence 17
Oral health -- Oral Cancer 17
Oral health – Oral health insurance 18
Oral health -- Dental visits 18
Oral health -- Child dental 18
Hypertension Awareness 19
Cholesterol Awareness 19
Diabetes 20
Folic Acid 22
Suicide
Sometimes people feel so depressed and hopeless about the future that they may
consider attempting suicide, that is, taking some action to end their own life. The next
four questions ask about attempted suicide.
1. During the past 12 months have you ever seriously considered
attempting suicide?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. If yes, during the past 12 months did you ever make a serious plan
about how you would attempt suicide?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. If yes, during the past 12 months, how many times did you actually
attempt suicide?
0 0 or none
1-76 Number of times
77 Don’t know/Not sure
99 Refused
4. Did any suicide attempt in the past 12 months result in an injury,
poisoning, or overdose that had to be treated by a doctor or nurse?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Residential Fire
1. When was the last time you or someone else deliberately tested
all of the smoke alarms in your home?
1 Within the past month (less than 1 month ago)
2 Within the past 6 months (at least 1 month but less than 6 mnths ago)
3 Within the past year (at least 6 months but less than 12 months ago)
4 One or more years ago
5 Never
6 No smoke alarms in home
DO NOT READ
7 DON’T KNOW/NOT SURE
9 Refused
2. Have you [fill fill] designed a detailed fire escape plan?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. How often do you [fill fill] practice your fire escape plan? Would you say:
1 Never
2 Less than once a year
3 Once a year
4 Once every six months
5 Once a month
6 More than once a month
DO NOT READ
7 DON’T KNOW/NOT SURE
9 Refused
Sexual Violence
These next questions may be hard for you to answer, but the information is very
important and, again, will be kept strictly confidential. These questions are about things
that might or might not have happened to you since you were 18 years old.
1. In the past 12 months, has anyone exposed you to unwanted sexual
situations that did not involve physical touching? Examples include
things like flashing you, peeping, sexual harassment, or making you
look at sexual photos or movies.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. 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?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. 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?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. 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?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
5. 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.
DO NOT READ
01 Complete stranger
02 A person known for less than 24 hours
03 Acquaintance
04 Friend
05 Date
06 Current boyfriend/girlfriend
07 Former boyfriend/ girlfriend
08 Spouse or live-in partner
09 Ex-spouse or ex live-in partner
10 Co-worker
11 Neighbor
12 Parent
13 Step-parent
14 Parent’s partner
15 Other relative
16 Other non-relative
17 Multiple perpetrators (skip gender)
77 Don’t know / Not sure
99 Refused
6. Was the person who did this male or female?
1 Male
2 Female
7 Don’t know / Not sure
9 Refused
7. 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?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
8. Has anyone EVER had sex with you after you said or showed that you
didn’t want them to or without your consent?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Intimate Partner Violence
1. 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.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
2. Has an intimate partner EVER hit, slapped, pushed, kicked, or
physically hurt you in any way?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. “Other than what you have already told me about” Has an intimate
partner EVER ATTEMPTED physical violence against you? This includes
times when they tried to hit, slap, push, kick, or otherwise physically
hurt you, but they were not able to.
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Have you EVER experienced any unwanted sex by a current or former
intimate partner?
1 Yes
2 No Go to next section or end interview
7 Don’t know / Not sure Go to next section or end interview
9 Refused Go to next section or end interview
5. In the past 12 months, have you experienced any physical violence or
had unwanted sex with an intimate partner?
1 Yes
2 No Go to next section or end interview
7 Don’t know / Not sure Go to next section or end interview
9 Refused Go to next section or end interview
6. 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?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. 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?
DO NOT READ
01 Boyfriend
02 Girlfriend
03 Former boyfriend
04 Former girlfriend
05 Male you were dating
06 Female you were dating
07 Husband or male live-in partner
08 Former husband or former male live-in partner
09 Wife or female live-in partner
10 Former wife or former female live-in partner
11 Other
77 Don’t know / Not sure
99 Refused
Closing Statement: We realize that this topic may bring up past experiences that some
people may wish to talk about. If you or someone you know would like to talk to a
trained counselor, there is a toll-free and confidential intimate partner violence telephone
hotline you can call. The number is 1- 800-799-SAFE
Anxiety and Depression Module
Now, I am going to ask you some questions about your mood. When answering these questions,
please think about how many days each of the following has occurred in the past 2 weeks.
1. Over the last 2 weeks, how many days have you had little interest or
pleasure in doing things?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
2. Over the last 2 weeks, how many days have you felt down, depressed or
hopeless?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
3. Over the last 2 weeks, how many days have you had trouble falling
asleep or staying asleep or sleeping too much?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
4. Over the last 2 weeks, how many days have you felt tired or had little
energy?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
5. Over the last 2 weeks, how many days have you had a poor appetite or
ate too much?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
6. Over the last 2 weeks, how many days have you felt bad about yourself –
or that you were a failure or had let yourself or your family down?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
7. Over the last 2 weeks, how many days have you had trouble
concentrating on things, such as reading the newspaper or watching TV?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
8. Over the last 2 weeks, how many days have you moved or spoken so
slowly that other people could have noticed? Or the opposite – being so
fidgety or restless that you were moving around a lot more than usual?
__ __ 01-14 days
8 8 None
7 7 Don’t know / Not sure
9 9 Refused
9. Has a doctor or other healthcare provider EVER told you that you have an
anxiety disorder (including acute stress disorder, anxiety, generalized
anxiety disorder, obsessive-compulsive disorder, panic attacks, panic
disorder, phobia, posttraumatic stress disorder, or social anxiety
disorder)?
1 Yes
2 No
7 Don’t know / not sure
9 Refused
10. Has a doctor or other healthcare provider EVER told you that you have a
depressive disorder (including depression, major depression, dysthymia,
or minor depression)?
1 Yes
2 No
7 Don’t know / not sure
9 Refused
Fruits and Vegetables
These next two questions are about the foods you usually eat or drink. Please tell me
how often you eat or drink each one, for example, twice a week, three times a month,
and so forth. Remember, I am only interested in the foods you eat. Include all foods you
eat, both at home and away from home.
1. Not counting juice, how often do you eat fruit?
<101-199> Times per day, <201-299> Times per week, <301-399>
Times per month, <401-499> Times per year, <555> Never, <777>
DK/NS, <999> Refused
2. How often do you eat green salad? <101-199> Times per day, <201-
299> Times per week, <301-399> Times per month, <401-499>
Times per year, <555> Never, <777> DK/NS, <999> Refused
Physical Activity
1. 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?
1 Yes
2 No
7 Don’t know/Not sure
9 Refused
We are interested in moderate physical activity. Moderate activities cause small
increases in breathing or heart rate.
2. Now, thinking about the moderate activities you do [fill in “when you
are not working” if “employed” or self-employed”] in a usual week,
do you do moderate activities for at least 10 minutes at a time, such as
brisk walking, bicycling, vacuuming, gardening, or anything else that
causes some increase in breathing or heart rate?
1 Yes
2 No Go to Q18.5
7 Don’t know / Not sure Go to Q18.5
9 Refused Go to Q18.5
3. How many days per week do you do these moderate activities for at
least 10 minutes at a time?
__ Days per week
88 Do not do any moderate physical activity for at least 10
minutes at a time Go to Q18.5
77 Don’t know / Not sure Go to Q18.5
99 Refused Go to Q18.5
4. 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?
_:_ _ Hours and minutes per day
777 Don’t know / Not sure
999 Refused
Secondhand Smoke Policy
1. Which statement best describes the rules about smoking inside your
home?
Please read
1 Smoking is not allowed anywhere inside your home
2 Smoking is allowed in some places or at some times
3 Smoking is allowed anywhere inside your home
or
4 There are no rules about smoking inside your home
DO NOT READ
7 Don’t know / Not sure
9 Refused
2. While working at your job, are you indoors most of the time?
1 Yes
2 No Go to next module
7 Don’t know / Not sure Go to next module
9 Refused Go to next module
3. Which of the following best describes your place of work’s official
smoking policy for indoor public or common areas, such as lobbies,
rest rooms, and lunch rooms?
Note: For workers who visit clients or work at home, “place of work”
means their base location. For self-employed persons who work at
home, the official smoking policy means the home smoking policy.
Please read
1 Not allowed in any public areas
2 Allowed in some public areas
3 Allowed in all public areas
4 No official policy
DO NOT READ
7 Don’t know / Not sure
9 Refused
4. Which of the following best describes your place of work’s official
smoking policy for work areas?
Please read
1 Not allowed in any work areas
2 Allowed in some work areas
3 Allowed in all work areas
4 No official policy
DO NOT READ
7 Don’t know / Not sure
9 Refused
Smoking Cessation
1. About how long has it been since you last smoked cigarettes? (DROP
for 2005; Keep for 2006) (354-355)
Read only if necessary:
01 Within the past month (anytime less than 1 month ago) Go to
02 Within the past 3 months (1 month but less than 3 months ago)
Go to Q2
03 Within the past 6 months (3 months but less than 6 months
ago) Go to Q2
04 Within the past year (6 months but less than 1 year ago)
Go to Q2
05 Within the past 5 years (1 year but less than 5 years ago) Go
to next module
06 Within the past 10 years (5 years but less than 10 years ago)
Go to the next module
07 10 or more years ago Go to next module
77 Don’t know / Not sure Go to next module
99 Refused Go to next module
2. In the last 12 months, how many times have you seen a doctor, nurse
or other health professional to get any kind of care for yourself?
__ Number of times [01-76]
88 None Go to next module
77 Don’t know / Not sure
99 Refused
3. In the last 12 months, on how many visits were you advised to quit
smoking by a doctor or other health provider?
__ Number of visits [01-76]
88 None
77 Don’t know / Not sure
99 Refused
4. On how many visits did your doctor, nurse or other health professional
recommend or discuss medication to assist you with quitting smoking,
such as nicotine gum, patch, nasal spray, inhaler, lozenge, or
prescription medication such as Wellbutrin/Zyban/Bupropion?
__ Number of visits [01-76]
88 None
77 Don’t know / Not sure
99 Refused
5. On how many visits did your doctor or health provider recommend or
discuss methods and strategies other than medication to assist you
with quitting smoking?
__ Number of visits [01-76]
88 None
77 Don’t know / Not sure
99 Refused
Follow-up to Second-Hand Smoking Policy:
1. In the following locations, do you think that smoking should be allowed in
all areas, some areas, or not allowed at all? At indoor work areas.
1 All areas
2 Some areas
3 Not allowed
7 Don’t know/Not sure
9 Refused
2. In the following locations, do you think that smoking should be allowed in
all areas, some areas, or not allowed at all? At a restaurant.
1 All areas
2 Some areas
3 Not allowed
7 Don’t know/Not sure
9 Refused
Follow-up to Smoking cessation:
1. Previously you said you have smoked cigarettes. Since the time you
started smoking, how many times have you tried to quit smoking?
1 Not at all
2 Once or twice
3 3 to 5 times
4 6 to 9 times
5 10 or more times
7 Don’t know/Not sure
9 Refused
Adult Asthma History
1. How old were you when you were first told by a doctor or other health
professional that you had asthma?
__ Age in years 11 or older [96=96 and older]
97 Age 10 or younger
98 Don’t know / Not sure
99 Refused
If “Yes” to Core Q9.2; continue. Otherwise, Go to next module.
2. During the past 12 months, have you had an episode of asthma or
an asthma attack?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
3. During the past 12 months, how many times did you visit an
emergency room or urgent care center because of your asthma?
__ Number of visits [87=87 or more]
88 None
98 Don’t know / Not sure
99 Refused
If one or more visits to Q3, fill in (besides those emergency room
visits).
4. During the past 12 months, how many times did you see a doctor,
nurse or other health professional for urgent treatment of worsening
asthma symptoms?
__ Number of visits [87=87 or more]
88 None
98 Don’t know / Not sure
99 Refused
5. During the past 12 months, how many times did you see a doctor,
nurse or other health professional for a routine checkup for your
asthma?
__ Number of visits [87=87 or more]
88 None
98 Don’t know / Not sure
99 Refused
6. During the past 12 months, how many days were you unable to work or
carry out your usual activities because of your asthma?
___ Number of days
888 None
777 Don’t know / Not sure
999 Refused
7. During the past 30 days, how often did you have any symptoms of
asthma? Would you say?
Please read
8 Not at any time Go to Q9
1 Less than once a week
2 Once or twice a week
3 More than 2 times a week, but not every day
4 Every day, but not all the time or
5 Every day, all the time
DO NOT READ
7 Don’t know / Not sure
9 Refused
8. During the past 30 days, how many days did symptoms of asthma
make it difficult for you to stay asleep?
Would you say?
Please read
8 None
1 One or two
2 Three to four
3 Five
4 Six to ten or
5 More than ten
DO NOT READ
7 Don’t know / Not sure
9 Refused
9. During the past 30 days, how often did you take a prescription asthma
medication to prevent an asthma attack from occurring?
Please read
1 Every day or almost every day
2 A few times a week
3 Less often
4 Never
7 Don’t know / Not sure
9 Refused
If Q2 = 2, 7, or 9 (No, Don’t Know, Refused), Go to next module.
10. During the past 30 days, how often did you use a prescription asthma
inhaler during an asthma attack to stop it?
INTERVIEWER INSTRUCTION: How often (number of times) does NOT
equal number of puffs. Two to three puffs are usually taken each time
the inhaler is used.
8 Never (include no attack in past 30 days)
1 One to four times (in the past 30 days)
2 Five to fifteen times (in the past 30 days)
3 Fifteen to twenty-nine time (in the past 30 days)
4 Thirty to fifty-nine times (in the past 30 days)
5 Sixty to ninety-nine times (in the past 30 days)
6 More than 100 times (in the past 30 days)
7 Don’t know / Not sure
9 Refused
Random Child Selection
Note: If there are two children with the same birth date, randomly select one.
1. What is the birth month and year of the child?
_ _/ _ _ _ _ Code month and year
7 7/ 7 7 7 7 Don’t know / Not sure
9 9/ 9 9 9 9 Refused
2. Is the child a boy or a girl?
1 Boy
2 Girl
9 Refused
3. Is the child Hispanic or Latino?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. Which one or more of the following would you say is the race of the
child? (
[Check all that apply]
Please read
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian, Alaska Native
or
6 Other [specify] ____________________
DO NOT READ
8 No additional choices
7 Don’t know / Not sure
9 Refused
If more than one response to Q4; continue. Otherwise, Go to Q6.
5. Which one of these groups would you say best represents the child’s
race?
1 White
2 Black or African American
3 Asian
4 Native Hawaiian or Other Pacific Islander
5 American Indian, Alaska Native
6 Other [specify] ____________________
7 Don’t know / Not sure
9 Refused
6. How are you related to the child?
Please read
1 Parent (mother or father) include biologic, step or adoptive
parent
2 Grandparent
3 Foster parent or guardian [other than parent or grandparent]
4 Sibling (brother or sister) include biologic, step and adoptive
sibling
5 Other relative
6 Not related in any way
DO NOT READ
7 Don’t know / Not sure
9 Refused
Childhood Asthma Prevalence
If “No” children (88) or Refused (99) to Core Q13.6; Go to Module 13.
1. Has a doctor or other medical professional EVER said that the child
has asthma?
1 Yes
2 No Go to next module
7 Don’t know / Not sure Go to next module
9 Refused Go to next module
2. Does the child still have asthma?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Oral health -- Oral Cancer
1. When was the last time you had a test for oral cancer in which a
doctor or dentist pulls on your tongue, sometimes with gauze
wrapped around it, feels under the tongue and inside the
cheeks?
<1> Within the past year (anytime less than 12 months ago),
<2> Within the past 2 years (1 year but less than 2 years ago),
<3> Within the past 5 years (2 years but less than 5 years ago),
<4> 5 or more years ago, <5> Never, <7> Don’t know / Not sure
<9> Refused
Oral health – Oral health insurance
1. Do you have any kind of insurance coverage that pays for some or all
of your routine dental care, including dental insurance, prepaid plans
such as HMOs, or government plans such as Medicaid?
<1> Yes, <2> No, <7> DK/NS, <9> Refused
Oral health -- Dental visits
1. How long has it been since you last visited the dentist or a dental
clinic?
<1> Within the past year (1 to 12 months ago), <2> Within the past 2
years (1 to 2 years ago), <3> Within the past 5 years (2 to 5 years
ago), <4> 5 or more years ago, <7> DK/NS, <8> Never, <9> Refused
1a. What is the main reason you have not visited the dentist in the last
year?
<1> Fear, apprehension, or nervousness, pain, <2> Dislike Cost,
<3> Do not have/know dentist, <4> Cannot get to the office/clinic (too
far), <5> No reason to go, <6> Other Priorities, <7> Have not thought
of it, <8> Other, <77> Don’t Know/ Not sure, <99> Refused
Oral health -- Child dental
1. Thinking about your youngest child, did you put this child to bed with a
bottle?
<1> Yes, <2> No, <7> Don't Know, <9> Refused
1a. At what age did this child stop taking a bottle to bed?
<1> 1 year old, <2> 2 year old, <3> 3 year old, <4> 4 year old, <5>
More than 4 years old, <8> Still doing it, <7> DK/NS, <9> Refused
Hypertension Awareness
1. Have you EVER been told by a doctor, nurse, or other health professional
that you have high blood pressure?
(86)
If “Yes” and respondent is female, ask: “Was this only when
you were pregnant?”
1 Yes
2 Yes, but female told only during pregnancy Go to next section
3 No Go to next section
4 Told borderline high or pre-hypertensive Go to next section
7 Don’t know / Not sure Go to next section
9 Refused Go to next section
2. Are you currently taking medicine for your high blood
pressure?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Cholesterol Awareness
1. Blood cholesterol is a fatty substance found in the blood. Have you
EVER had your blood cholesterol checked?
1 Yes
2 No Go to next section
7 Don’t know / Not sure Go to next section
9 Refused Go to next section
2. About how long has it been since you last had your blood cholesterol
checked?
Read only if necessary:
1 Within the past year (anytime less than 12 months ago)
2 Within the past 2 years (1 year but less than 2 years ago)
3 Within the past 5 years (2 years but less than 5 years ago)
4 5 or more years ago
7 Don’t know / Not sure
9 Refused
3. Have you EVER been told by a doctor, nurse or other health professional
that your blood cholesterol is high?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
Diabetes
1. How old were you when you were told you have diabetes?
__ Code age in years [97=97 and older]
98 Don’t know / Not sure
99 Refused
2. Are you now taking insulin?
1 Yes
2 No
9 Refused
3. Are you now taking diabetes pills?
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
4. About how often do you check your blood for glucose or sugar? Include times
when checked by a family member or friend, but do NOT include times when checked
by a health professional.
1__ Times per day
2__ Times per week
3__ Times per month
4__ Times per year
888 Never
777 Don’t know / Not sure
999 Refused
5. About how often do you check your feet for any sores or irritations? Include
times when checked by a family member or friend, but do NOT include times when
checked by a health professional. (208-210)
1__ Times per day
2__ Times per week
3__ Times per month
4__ Times per year
888 Never
555 No feet
777 Don’t know / Not sure
999 Refused
6. Have you EVER had any sores or irritations on your feet that took more than four
weeks to heal?
(211)
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
7. About how many times in the past 12 months have you seen a doctor, nurse, or
other health professional for your diabetes?
(212-213)
__ Number of times [76=76 or more]
88 None
77 Don’t know / Not sure
99 Refused
8. A test for "A one C" measures the average level of blood sugar over the past
three months. About how many times in the past 12 months has a doctor, nurse, or
other health professional checked you for
"A one C"? (214-215)
__ Number of times [76=76 or more]
88 None
98 Never heard of "A one C" test
77 Don’t know / Not sure
99 Refused
If Q5= 555 (No Feet); Go to Q10.
9. About how many times in the past 12 months has a health professional checked
your feet for any sores or
irritations? (216-217)
__ Number of times [76=76 or more]
88 None
77 Don’t know / Not sure
99 Refused
10. When was the last time you had an eye exam in which the pupils were dilated?
This would have made you
temporarily sensitive to bright light. (218)
Read only if necessary:
1 Within the past month (anytime less than 1 month ago)
2 Within the past year (1 month but less than 12 months ago)
3 Within the past 2 years (1 year but less than 2 years ago)
4 2 or more years ago
8 Never
7 Don’t know / Not sure
9 Refused
11. Has a doctor EVER told you that diabetes has affected your eyes or that you had
retinopathy?
(219)
1 Yes
2 No
7 Don’t know / Not sure
9 Refused
12. Have you EVER taken a course or class in how to manage your diabetes
yourself? (220)
1 Yes
2 No
7 Don't know / Not sure
9 Refused
Folic Acid
Do you currently take any vitamin pills or supplements?
(INCLUDE LIQUID SUPPLIMENTS)
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Are any of these a multivitamin?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
Do any of the vitamin pills or supplements you take contain folic acid?
1 Yes
2 No
7 Don't know/Not sure
9 Refused
How often do you take this vitamin pill or supplement?
CODE WHETHER RESPONDENT ANSWERS IN DAYS,WEEKS, OR MONTHS
1 Per day
2 Per week
3 Per month]
7 DON'T KNOW/NOT SURE]
9 REFUSED
1-99 TIMES PER DAY
IF RESPONDENT 45 YEARS OR OLDER, GO TO NEXT MODULE
Some health experts recommend that women take 400 micrograms of
the B vitamin folic acid, for which one of the following
reasons...
(READ RESPONSES)
1 To make strong bones
2 To prevent birth defects
3 To prevent high blood pressure
4 Some other reason
7 DON'T KNOW/NOT SURE
9 REFUSED
Reasons for not taking vitamins/mineral supplements daily (main reason)
Forget to take
No particular reason
Don’t feel I need them
Get balanced nutrition
Lazy
The cost/costs too much
Stomach problem
Never thought about
Other
