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DEMOGRAPHICS

   Gender
   Age
   Age (18-24, 25-44, 45-64, 65+)
   Are you Hispanic or Latino?
   Which one of these groups would you say best represents your race?
   Marital status?
   What is the highest grade or year of school completed?
   Education
   Employed
   What is your current employment status?
   Which of the following categories best describes your annual household income from all sources?
   Income [4 Categories]
   Adults in household
   Adult Males
   Adult Females
   How many children less than 18 years of age live in your household?
   Zip Code
   Have you ever served on active duty in the United States Armed Forces?


HEALTH STATUS

   Would you say that in general your health is:
   Now thinking about your physical health, for how many days during the past 30 days was your physical health not good?
   CDC physical health
   Now thinking about your mental health, for how many days during the past 30 days was your mental health not good?
   CDC mental health
   During the past 30 days, for about how many days did poor physical or mental health keep you from doing usual activities?


HEALTHCARE ACCESS

   Do you have any kind of health coverage?
   Are you currently covered by any of the following types of health insurance or health coverage plans?
   During the past 12 months, was there any time that you did not have any health insurance/coverage?
   Do you have one person you think of as your personal doctor or health care provider?
   Was there a time during the past 12 months when you needed to see a doctor but could not because of the cost?
   About how long has it been since you last visited a doctor for a routine checkup?
   What was the main reason you are without health coverage?
   About how long has it been since you had health care coverage?
   What was the main reason you were without health coverage during the past 12 months?
   How satisfied are you with your access to regular health care?
   What is the most important reason that you are [insert satisfaction level]?
   Is there one particular doctor or health pro. who you usually go to when you need routine care?
   What kind of place is it? Would you say:
   What is the main reason you do not have a usual source of medical care?
   If more than one, is there one of these places that you go to most often when you are sick or need advice about your health?
   How would you rate your satisfaction with your overall health care?
   Used an ER for any reason?
   How many times during the last 12 months have you or a member of your household used an ER for any reason?
   How do you usually get to your medical appointments?
   About how long have you had [medicare/medicaid/particular health insurance]?
   Is there a book or list of doctors associated with your plan?
   Does this plan require that you sign up with a certain doctor or clinic for all your routine care?
   Do you have any other type of health care coverage?
   Thinking of the distance/time you travel to get to the place you usually go, how would you rate the convenience of that place?
   When did you last change doctors?
   Why did you change doctors that last time?


AFFORDABLE CARE ACT

   Have you made any attempt to try and obtain Health Insurance Coverage from the Health Insurance Marketplace?
   Were you able to secure coverage through the Health Insurance Martketplace?
   Is your policy still active?
   How satisfied were you with the experience of the Health Insurance Marketplace?


HYPERTENSION AWARENESS

   Have you ever been told by a doctor or other health professional that you have high blood pressure?
   Are you currently taking medicine for your high blood pressure?
   About how long has it been since you last had your blood pressure taken?
   Have you been told on more than one occasion that your blood pressure was high, or have you been told this only once?


BLOOD CHOLESTEROL AWARENESS

   Have you ever had your blood cholesterol checked?
   About how long has it been since you last had your blood cholesterol checked?
   Have you ever been told by a doctor or other health professional that you have high blood cholesterol?


CHRONIC HEALTH CONDITIONS

   Has a doctor, nurse, or other health professional ever told you that you had a heart attack, also called a myocardial infarction?
   Has a doctor, nurse, or other health professional ever told you that you had angina or coronary heart disease?
   Has a doctor, nurse, or other health professional ever told you that you had a stroke?
   Have you ever been told by a doctor, nurse, or other health professional that you had asthma?
   Do you still have asthma?
   Has a doctor, nurse, or other health professionaL ever told you have COPD (chronic obstructive pulmonary disease, emphysema or chronic bronchitis)?
   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?
   Have you Ever been told you have a depressive disorder (including depression, major depression, dysthymia, or minor depression?
   Have you ever been told by a doctor or other health professional that you have diabetes?


IMMUNIZATION

   During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose?
   At what kind of place did you get your last flu shot/vaccine?
   During the past 12 months, have you had either a seasonal flu shot or a seasonal flu vaccine that was sprayed in your nose?
   At what kind of place did you get your last flu shot/vaccine?
   Have you ever had a pneumonia vaccination?
   Since 2005, have you had a tetanus shot or a Tdap shot?


EXERCISE

   During the past month, did you participate in any physical activities or exercises?
   BMI (Body Mass Index)
   Are you now trying to lose weight?
   Are you now trying to maintain your current weight, that is to keep from gaining weight?
   Are you eating fewer calories to lose weight/keep from gaining weight?
   Are you using physical activity or exercise to lose weight/keep from gaining weight?
   In the past 12 months, has a doctor, nurse or other health professional given you advice about your weight?


TOBACCO USE

   Current Smoke Rate
   Have you smoked at least 100 cigarettes in your entire life?
   Do you now smoke cigarettes everyday, some days, or not at all?
   During the past 12 months, have you quit smoking for one day or longer?


OTHER TOBACCO PRODUCTS

   Do you currently use chewing tobacco or snuff every day, some days, or not at all?
   Do you currently use cigars, pipes, bidis, kreteks or other tobacco products?
   Have you ever tried an e-cigarette?
   Do you currently use e-cigarettes every day, some days, or not at all?
   What is the primary reason for using e-cigarettes?


SECOND HAND SMOKE

   To what degree do you agree with the statement, "Breathing in someone else's cigarette smoke is harmful to your health."
   On how many of the past 7 days, did someone smoke in your indoor workplace while you were there?
   On how many of the past 7 days, did anyone smoke in your home while you were there?


TOBACCO POLICIES

   Which statement best describes the rules about smoking inside your home ?
   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?
   Which of the following best describes your place of work's official smoking policy for work areas?
   In bars, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
   In restaurants, do you think that smoking should be allowed in all areas, some areas, or not allowed at all?
   In schools, do you think that smoking should be allowed in all areas, some areas, or not allowed at all?
   In day care centers. do you think that smoking should be allowed in all areas, some areas, or not allowed at all?
   In indoor work areas, do you think that smoking should be allowed in all areas, some areas, or not allowed at all?
   At outside public spaces such as parks, playgrounds, youth sporting events, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
   Do you think that billboards that advertise tobacco products should be allowed near places frequented by children, such as schools, playgrounds, and churches?


ALCOHOL CONSUMPTION

   During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage?
   On the days when you drank, about how many drinks did you drink on the average?
   Considering all types of alcoholic beverages, how many times during the past month did you have 5 or more drinks on an occasion?
   During the past 30 days, what is the largest number of drinks you had on any occasion?
   And during the past month, how many times have you driven when you've had perhaps too much to drink?
   During the past month, how many times have you ridden with a driver who has had perhaps too much to drink?


BINGE DRINKING

   Binge Drinking
   During the most recent occasion when you had 5 or more alcoholic beverages, about how many beers, including malt liquor, did you drink?
   During the same occasion, about how many glasses of wine did you drink?
   During the same occasion, about how many drinks of liquor, including cocktails, did you have?
   During the same occasion, about how many other pre-mixed, flavored drinks did you have? By that, we mean drinks such as hard lemonade, wine coolers, or Smirnoff Ice.
   During this most recent occasion, where were you when you did most of your drinking?
   Did you drive a motor vehicle such as a car, truck, or motorcycle during or within a couple of hours after this occasion?
   During this most recent occasion, approximately how much did you pay for the alcohol which you drank?


SEATBELT USE

   How often do you use seat belts when you drive or ride in a car? Would you say...


DISTRACTED DRIVING

   How often do you eat or drink while driving?
   How often do you make or accept phone calls while driving?
   How often do you read [book, newspaper, iPad] while driving?
   How often do you read e-mails or text messages while driving?
   How often do you send e-mails or text messages while driving?
   How often do you do personal grooming [make-up, shave] while driving?
   How often do you use a portable music player, including smart phone while driving?
   How often do you use smart phone/navigation system while driving?


WOMEN'S HEALTH

   Based on your knowledge and feelings today, if you were about to have a baby, would you breastfeed or support your partner's decision to breastfeed?
   To your knowledge, are you now pregnant?
   Have you ever had a mammogram?
   How long has it been since you had your last mammogram?
   Was your last mammogram done as part of a routine checkup, because of a breast problem other than cancer, or because you've already had breast cancer?
   What was your main reason for not having a mammogram?
   Have you ever had a clinical breast exam?
   How long has it been since your last breast exam?
   Was your last breast exam done as part of a routine checkup, because of a breast problem other than cancer, or because you've already has breast cancer?
   A Pap smear is a test for cancer of the cervix. Have you ever had a Pap smear?
   How long has it been since you had your last Pap smear?
   Was your last Pap smear done as part of a routine exam, or to check a current or previous problem?
   Have you had a hysterectomy?


PROSTRATE CANCER SCREENING

   Have you ever had a Prostate-Specific Antigen (PSA) test
   How long has it been since you had your last PSA test ?
   Have you ever had a digital rectal exam ?
   How long has it been since your last digital rectal exam ?
   Have you ever been told by a doctor that you had prostate cancer ?
   Has your father, brother, son, or grandfather ever been told they have prostate cancer ?


COLORECTAL CANCER SCREENING

   Have you ever used a special kit at home to determine whether your stool contains blood?
   When did you have your last blood stool test using a home kit?
   Have you ever had a sigmoidoscopy or colonoscopy?
   Was your MOST RECENT exam a sigmoidoscopy or a colonoscopy?
   When did you have your last sigmoidoscopy or colonoscopy?


HIV/AIDS

   Have you ever been tested for HIV?
   Where did you have your last HIV test?
   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.


FRUITS & VEGETABLES

   How often do you drink fruit juices such as orange, grapefruit, or tomato?
   Not counting juice, how often do you eat fruit?
   Not counting carrots, potatoes, or salad, how often do you eat vegetables?
   How often do you eat green salad?
   How often do you eat potatoes not including french fries, fried potatoes, or potato chips?
   How often do you eat carrots?


DISABILITY

   Are you limited in any way in any activities because of physical, mental, or emotional problems?
   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?
   During the past 30 days, have you had any symptoms of pain, aching, or stiffness in or around a joint?
   Did your joints symptoms FIRST begin more than 3 months ago?
   Have you ever seen a doctor or other health professional for these joint symptoms?
   Were these symptoms present on most days for at least one month ?


EMOTIONAL SUPPORT & LIFE SATISFACTION

   How often do you get the social and emotional support you need ?
   In general, how satisfied are you with your life ?


QUALITY OF LIFE

   During the past 30 days, for about how many days did pain make it hard for you to do your usual activities?
   During the past 30 days, for about how many days have you felt sad, blue, or depressed?
   During the past 30 days, for about how many days have you felt worried, tense, or anxious?
   During the past 30 days, for about how many days have you felt you did not get enough rest or sleep?
   During the past 30 days, for about how many days have you felt very healthy and full of energy?
   I believe my spiritual health affects my mental and physical health?


ORAL HEALTH

   Was there a time during the past 12 months when you needed to see a dentist but could not because of cost?
   How long has it been since you last visited a dentist or a dental clinic for any reason?
   How many of your permanent teeth have been removed because of tooth decay or gum disease?
   How long has it been since you had your teeth cleaned by a dentist or dental hygienist?
   What is the main reason you have not visited the dentist in the past year ?
   Do you have any kind of insurance coverage that pays for some or all of your routine dental care?


DIABETES

   Have you had a test for high blood sugar or diabetes within the past three years?
   Have you ever been told by a doctor or other health professional that you have pre-diabetes or borderline diabetes?
   How old were you when you were told you have diabetes?
   Are you now taking insulin?
   Are you now taking diabetes pills?
   About how often do you check your blood for glucose or sugar?
   About how often do you check your feet for any sores or irritations?
   Have you ever had any sores or irritations on your feet that took more than four weeks to heal?
   About how many times in the past 12 months have you seen a doctor, nurse, or other health professional for your diabetes?
   About how many times in the past 12 months has a doctor, nurse, or other health professional checked you for A one C?
   About how many times in the past 12 months has a health professional checked your feet for any sores or irritations ?
   When was the last time you had an eye exam in which the pupils were dilated?
   Has a doctor ever told you that diabetes has affected your eyes or that you had retinopathy?
   Have you ever taken a course or class in how to manage your diabetes yourself?


CARDIOVASCULAR DIESEASE

   At what age did you have your first heart attack?
   At what age did you have your first stroke?
   Do you take aspirin daily or every other day?
   Do you have a health problem or condition that makes taking aspirin unsafe for you?
   Do you take aspirin to relieve pain?
   Do you take aspirin to reduce the chance of a heart attack?
   Do you take aspirin to reduce the chance of a stroke?
   To lower your risk of developing heart disease or stroke, are you eating fewer high fat or high cholesterol foods?
   To lower your risk of developing heart disease or stroke, are you eating more fruits and vegetables?
   To lower your risk of developing heart disease or stroke, are you more physically active?
   Within the past 12 months, has a doctor, nurse, or other health professional told you to eat fewer high fat or high cholesterol foods?
   Within the past 12 months, has a doctor, nurse, or other health professional told you to eat more fruits and vegetables?
   Within the past 12 months, has a doctor, nurse, or other health professional told you to be more physically active?
   After you left the hospital following your heart attack and/or stroke, did you go to any kind of outpatient rehabilitation? This is sometimes called rehab.


ARTHRITIS BURDEN

   Are you now limited in any way of your usual activities because of arthritis or joint symptoms?
   Do arthritis or joint symptoms now affect whether you work, the type of work you do or the amount of work you do?
   Are you currently being treated by a doctor for arthritis ?


PHYSICAL ACTIVITY

   When you are at work, which of the following best describes what you do? Would you say:
   In a usual week, do you do moderate activities for at least 10 minutes at a time?
   How many days per week do you do these moderate activities for at least 10 minutes at a time?
   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?
   In a usual week, do you do vigorous activities for at least 10 minutes at a time?
   How many days per week do you do these vigorous activities for at least 10 minutes at a time?
   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?


MENTAL ILLNESS AND STIGMA

   About how often during the past 30 days did you feel nervous?
   During the past 30 days, about how often did you feel hopeless?
   During the past 30 days, about how often did you feel restless or fidgety?
   During the past 30 days, about how often did you feel so depressed that nothing could cheer you up?
   During the past 30 days, about how often did you feel that everything was an effort?
   During the past 30 days, about how often did you feel worthless?
   During the past 30 days, for about how many days did a mental health condition or emotional problem keep you from doing your work or other usual activities?
   Are you now taking medicine or receiving treatment from a doctor or other health professional for any type of mental health condition or emotional problem?
   Do you agree that treatment can help people with mental illness lead normal lives.
   Do you agree that people are generally caring and sympathetic to people with mental illness.


SUNBURN

   Have you had sunburn within the past 12 months?
   How many sunburns have you had within the past 12 months?


SAFETY

   What is the age of the oldest child in your household under the age of 18?
   During the past year how often has the child worn a bicycle helmet when riding a bicycle?
   When was the last time you or someone else deliberately tested all of the smoke detectors in your home?


CHILD HEALTH

   How are you related to the children in your house?
   Where does/do the child/children in your household usually go for regular health care?
   Does the child in your household have any kind of health coverage?
   Was there a time during the past 12 months when a child living in your household needed to see a doctor, but could not because of cost?
   Have any children in your household experienced moderate or major behavioral or emotional problems in the past 6 months?
   Have you or anyone in your household looked for help to address this problem?
   Did you get help?
   Do any children in your household need help for this problem?


SOCIAL CONTEXT

   Do you own or rent?
   How long have you lived at your current address?
   How many times in the past 12 months would you say you were worried or stressed about having enough money to pay your rent/mortgage?
   How many times in the past 12 months would you say you were worried or stressed about having enough money to buy nutrititous meals for your family?
   At your main job or business, how are you generally paid for the work you do?
   About how many hours do you work per week on all of your jobs and businesses combined?
   Did you vote in the last presidential election? The November 2008 election between Barack Obama and John McCain?


GENERAL PREPAREDNESS

   How well prepared do you feel your household is to handle a large-scale disaster or emergency?
   Does your household have a 3-day supply of water for everyone who lives there?
   Does your household have a 3-day supply of nonperishable food for everyone who lives there?
   Does your household have a 3-day supply of prescription medication for each person who takes prescribed medicines?
   Does your household have a working battery operated radio and working batteries for your use if the electricity is out?
   Does your household have a working flashlight and working batteries for your use if the electricity is out?
   In a large-scale disaster or emergency, what would be your main method or way of communicating with relatives and friend
   What would be your main method or way of getting information from authorities in a large-scale disaster or emergency?
   Does your household have a written disaster evacuation plan for how you will leave your home, in case of a large-scale disaster?
   If public authorities announced a mandatory evacuation from your community due to a large-scale disaster or emergency, would you evacuate?
   What would be the main reason you might not evacuate if asked to do so?
   Have you ever tried an e-cigarette?
   At outside public spaces such as parks, playgrounds, youth sporting events, do you THINK smoking should be allowed in all areas, some areas or not allowed at all?
   To what degree would you agree or disagree with the statement, "Breathing in someone else?s cigarette smoke is harmful to your health."
   Would you support such a law in your community that would make workplaces smoke-free by prohibiting smoking in all indoor workplaces, including restaurants, bars and casinos.?
   Missouri state law allows designated smoking areas in restaurants and other public places. Would you support a change in the state law that would make all workplaces smoke-free by prohibiting smoking in all indoor workplaces, including restaurants, bars a
   In the past 30 days, have you seen, read or heard any ads about quitting smoking cigarettes?
   Are you aware of the Missouri Tobacco Quitline services that are available to help people quit smoking?
   During the past 30 days, to what extent has your arthritis or joint symptoms interfered with your normal social activities, such as going shopping, to the movies, or to religious or social gatherings?
   Please think about the past 30 days, keeping in mind all of your joint pain or aching and whether or not you have taken medication. DURING THE PAST 30 DAYS, how bad was your joint pain ON AVERAGE?

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