National Population Health Survey

Content For Main Survey

March 25, 1994

DRAFT

Table of Contents

Household Record Variables	3

Proxy Interview	6

Two-Week Disability	6

Health Care Utilization	6

Restriction of Activities	8

Chronic Conditions	10

Socio-demographic Characteristics	11

Country of Birth/Year of Immigration	11

Ethnicity	11

Language	12

Race	12

Education	12

Labour Force	14

Income	17

Administration	18

Non-proxy Interview	19

General Health	19

Height/Weight	19

Preventive Health Practices	19

Smoking	20

Alcohol	21

Physical Activities	23

Injuries	25

Stress	27

Ongoing Problems	27

Recent Life Events	29

Childhood and adult stressors("traumas")	30

Work Stress	31

Self-Esteem and Mastery	31

Sense of Coherence	32

Health Status	35

Vision	35

Hearing	36

Speech	37

Getting Around	37

Hands and Fingers	38

Feelings	39

Memory	39

Thinking	39

Pain and Discomfort	39

Drug Use	40

Mental Health	41

Social Support	46

Health Number	48

Agreement to Share	48

Notes:	50

Household Record Variables

(To be collected at initial contact from knowledgeable person)

DEMO_INT	The next few questions will provide important basic information on the people in your household.

DEMO_Q1	What are the names of all persons now living or staying here who have no usual place of residence elsewhere?

(First and last names )

DEMO_Q2	Are there any persons away from this household attending school, visiting, travelling or in hospital who usually live here?

___	Yes	(go to DEMO-Q1)

___	No

DEMO_Q3	Does anyone else live at this dwelling such as relatives, roomers, boarders or employees?

___	Yes	(go to DEMO-Q1)

___	No

DEMO_Q4	What is ... 's date of birth?

DD/MM/YY (Age is calculated and confirmed with respondent.)

DEMO_Q5	Enter or ask ... 's sex.

___	Male

___	Female

DEMO_Q6	What is ... current marital status?

(Note: if age < 15,marital status is automatically = single)

___	Now married

___	Common-law

___	Living with a partner

___	Single (never married)

___	Widowed

___	Separated

___	Divorced

DEMO_Q7	Enter ... 's family Id code.

(A to Z)

Legal household check.

Reject household at this point if screening criteria are not met.

Selection criteria applied.

DEMO_Q8	Relationships of everyone to everyone else;

Birth Parent	Common law partner

Step Parent	In-law

Foster Parent	Other Related

Birth Child	Unrelated

Step Child	Husband/Wife

Foster Child	Adopted Child

Sister/brother	Adoptive Parent

Grandparent	Same-sex Partner

Grandchild

HHLD_Q1	Now a few questions about your dwelling. Is this dwelling owned by a member of this household (even if being paid for)?

___	Yes

___	No

HHLD_Q3	How many bedrooms are there in this dwelling?

(If no separate, enclosed bedroom enter "00".)

___	number of bedrooms (2 digits)

HHLD_Q4	Is there a pet in this household?

___	Yes

___	No	(Go to HHLD-Q6)

HHLD_Q5	What kind of pet?

(Do not read list. Mark all that apply)

___	Dog

___	Cat

___	Other	(Go to HHLD-Q6)

HHLD_Q5a	Does this pet or do any of these pets live mainly indoors?

___	Yes

___	No

HHLD_Q6	Record type of dwelling (by interviewer observation)

___	Single detached house

___	Semi-detached or double (side-by-side)

___	Garden house, town-house or row house

___	Duplex (one above the other)

___	Low-rise apartment (less than 5 stories)

___	High-rise apartment (5 or more stories)

___	Institution

___	Hotel, rooming or lodging house, logging or construction camp, Hutterite Colony

___	Mobile home

___	Other (Specify _____________)

HHLD_Q7	Information Source Indicator i.e. who is providing the information

HHLD_Q8	Record language of interview

English	Persian (Farsi)

French	Polish

Arabic	Portuguese

Chinese	Punjabi

Cree	Spanish

German	Tagalog (Filipino)

Greek	Ukrainian

Hungarian	Vietnamese

Italian	Other (Specify_________)

Korean

Proxy Interview

(To be completed for all members of the household)

If collection period=6 or if age of selected person <12, the interviewer should ask for the child's main caregiver to respond on behalf of family members.

H05-P1	Who is providing the information for this person's form?

_______________________________

Two-Week Disability

TWOWK-INT	The first few questions ask about ...(r/'s) health during the past 14 days.

TWOWK-Q1	It is important for you to refer to the 14-day period from %2WKSAGO% to %YESTERDAY%. During that period, did ... stay in bed at all because of illness or injury including any nights spent as a patient in a hospital?

___	Yes

___	No	(Go to TWOWK-Q3)

TWOWK-Q2	How many days did ... stay in bed for all or most of the day?

___	Days	(Enter <0> if less than a day.)

(If = 14 days go to TWOWK-Q5)

TWOWK-Q3	(Not counting days spent in bed) During those 14 days, were there any days that ... cut down on things you/he/she normally do/does because of illness or injury?

___	Yes

___	No	(Go to TWOWK-Q5)

TWOWK-Q4	How many days did ... cut down on things for all or most of the day?

___	Days

(Enter <0> if less than a day.)

TWOWK-Q5	Do(es) ... have a regular medical doctor?

___	Yes

___	No

Health Care Utilization

UTIL-CINT	If age<12, go to next section.

UTIL-INT	Now I'd like to ask about ...(r/'s) contacts with health professionals during the past 12 months.

UTIL-Q1	In the past 12 months, have/has ... been a patient overnight in a hospital, nursing home or convalescent home?

___	Yes

___	No	(Go to UTIL-Q2)

UTIL-Q1a	For how many nights in the past 12 months?

___	nights

UTIL-Q2	(Not counting when ... were/was an overnight patient) In the past 12 months, have/has ... seen or talked on the telephone with [fill category] about your/his/her physical, emotional or mental health:

Note: a) to e) have been reordered

a)	General practitioner or family physician

b)	Eye specialist (such as an ophthalmologist or optometrist)

c)	Other medical doctor (such as surgeon, allergist, gynaecologist, psychiatrist, etc.)

d)	A nurse for care or advice

e)	Dentist or orthodontist

f)	Chiropractor

g)	Physiotherapist

h)	Social worker or counsellor

i)	Psychologist

j)	Speech, audiology or occupational therapist

For each response >0 in a), c), or d), ask UTIL-Q3.

UTIL-Q3	Where did the most recent contact take place?

(Read list. Mark one only.)

___	Walk-in clinic

___	Outpatient clinic in hospital

___	Hospital emergency room

___	Health professional's office

___	Community health centre /CLSC

___	At home

___	Telephone consultation only

___	Other	(Specify_____________)

UTIL-Q4	People may also use alternative health care services. In the past 12 months, have/has ... seen or talked to an alternative health care provider such as an acupuncturist, naturopath, homeopath or massage therapist about your/his/her physical, emotional or mental health?

___	Yes

___	No	(Go to UTIL-Q6)

UTIL-Q5	Who did ... see or talk to?

(Do not read list. Mark all that apply.)

___	Massage therapist

___	Acupuncturist

___	Homeopath or naturopath

___	Feldenkrais or Alexander teacher

___	Relaxation therapist

___	Biofeedback teacher

___	Rolfer

___	Herbalist

___	Reflexologist

___	Spiritual healer

___	Religious healer

___	Self help group (such as AA, cancer therapy, etc.)

___	Other	(Specify _____________________)

UTIL-Q6	During the past 12 months, was there ever a time when you/he/she needed health care or advice but did not receive it?

___	Yes

___	No	(Go to UTIL-C9)

UTIL-Q7	Thinking of the most recent time, why did ... not get care?

____________________________________

UTIL-Q8	Again, thinking of the most recent time, what was the type of care that was needed?

(Do not read list. Mark all that apply.)

___	Treatment of a physical health problem

___	Treatment of an emotional or mental health problem

___	A regular check-up (or for regular pre-natal care)

___	Care of an injury

___	Any other reason (Specify______________)

UTIL-C9	IF age < 18 then go to next section.

UTIL-Q9	Home care services are health care or homemaker services received at home, with the cost being entirely or partially covered by government. Examples are: nursing care; help with bathing; help around the home; physiotherapy; counselling; and meal delivery. Have/Has ... received any home care services in the past 12 months?

___	Yes

___	No	(Go to next section)

UTIL-Q10	What type of services have/has ... received?

(Specify______________________)

Restriction of Activities

RESTR-CINT	If age<12, go to next section.

RESTR-INT	The next few questions deal with any health limitations which affect ... (r/'s) daily activities. In these questions, "long-term conditions" refer to conditions that have lasted or are expected to last 6 months or more.

RESTR-Q1	Because of a long-term physical or mental condition or a health problem, are/is ... limited in the kind or amount of activity you/he/she can do:

a)	at home?

___	Yes

___	No

b)	at school?

___	Yes

___	No

___	Not applicable

c)	at work?

___	Yes

___	No

___	Not applicable

d)	in other activities such as transportation to or from work or leisure time activities?

___	Yes

___	No

RESTR-Q2	Do(es) ... have any long term disabilities or handicaps?

___	Yes

___	No

If any yes in RESTR-Q1 (a)-(d), ask RESTR-Q3.

If yes in RESTR-Q2 only, ask RESTR-Q4.

Otherwise go to RESTR-Q6.

RESTR-Q3	What is the main condition or health problem causing ... to be limited in your/his/her activities?

___________________(25 spaces) (Go to RESTR-Q5)

RESTR-Q4	What is the main condition or health problem causing ... to have a long term disability or handicap?

___________________(25 spaces)

RESTR-Q5	Which one of the following is the best description of the cause of this condition?

(Read list. Mark one only.)

___	Injury - at home

___	Injury - sports or recreation

___	Injury - motor vehicle

___	Injury - work-related

___	Existed at birth

___	Work environment

___	Disease or illness

___	Natural aging process

___	Psychological or physical abuse

___	Other (Specify____________________)

RESTR-Q6	The next question asks about assistance, which may not apply to ... , but we need to ask the same question of everyone. Because of any condition or health problem, do(es) ... need the help of another person in:

(Read list. Mark all that apply.)

___	Preparing meals?

___	Shopping for groceries or other necessities?

___	Doing normal everyday housework?

___	Doing heavy household chores such as washing walls, yard work, etc.?

___	Personal care such as washing, dressing or eating?

___	Moving about inside the house?

___	None of the above

Chronic Conditions

CHRON-CINT	If age<12 go to next section.

CHRON-INT	Now I'd like to ask about any chronic health conditions ... may have. Again, "long-term conditions" refer to conditions that have lasted or are expected to last 6 months or more.

CHRON-Q1	Do(es) ... have any of the following long-term conditions that have been diagnosed by a health professional:

(Read list. Mark all that apply.)

(a)	Food allergies?

(b)	Other allergies?

(c)	Asthma?(If YES ask CHRON-Q1cc1)

(d)	Arthritis or rheumatism?

(e)	Back problems excluding arthritis?

(f)	High blood pressure?

(g)	Migraine headaches?

(h)	Chronic bronchitis or emphysema?

(i)	Sinusitis?

(j)	Diabetes?

(k)	Epilepsy?

(l)	Heart disease?

(m)	Cancer? (If yes ask CHRON-Q1mm)

(n)	Stomach or intestinal ulcers?

(o)	Effects of stroke?

(p)	Urinary incontinence?

(q)	Acne requiring prescription medication?	(Ask if age<30)

For persons aged < 18 years go to (u).

(r)	Alzheimer's disease or other dementia?

(s)	Cataracts?

(t)	Glaucoma?

(u)	Any other long term condition?	(Specify ______________)

(v)	None

CHRON-Q1mm	What type(s) of cancer is this? For example, skin, lung or colon cancer.

__________________________

CHRON-Q1cc1	Have/Has ... had an attack of asthma in the past 12 months?

___	Yes

___	No

CHRON-Q1cc2	Have/Has ... had wheezing or whistling in the chest at any time in the past 12 months?

___	Yes

___	No

Socio-demographic Characteristics

SOCIO-INT	Now I'd like to ask some general questions about the characteristics of people in your household.

Country of Birth/Year of Immigration

SOCIO-Q1	In what country were/was ... born?

(Do not read list. Mark one only.)

___	Canada	(Go to next section)

___	China	___	Jamaica

___	France	___	Netherlands

___	Germany	___	Philippines

___	Greece	___	Poland

___	Guyana	___	Portugal

___	Hong Kong	___	United Kingdom

___	Hungary	___	United States

___	India	___	Viet Nam

___	Italy	___	Other (Specify___)

SOCIO-Q3	In what year did ... first immigrate to Canada?

___	Year	(4 digits)

(Enter <1999> if Canadian citizen by birth.)

Ethnicity

SOCIO-Q4	To which ethnic or cultural group(s) did your/his/her ancestors belong? (For example: French, British, Chinese, etc.)

(Do not read list. Mark all that apply.)

___	Canadian	___	Chinese

___	French	___	Jewish

___	English	___	Polish

___	German	___	Portuguese

___	Scottish	___	South Asian

___	Irish	___	Black

___	Italian	___	North American Indian

___	Ukrainian	___	Métis

___	Dutch (Netherlands)	___	Inuit/Eskimo

___	Other ethnic or cultural group(s) (Specify___)

Note: former SOCIO-Q4 (registered Indian) question has been deleted.

Language

SOCIO-Q5	In which languages can ... conduct a conversation?

(Do not read list. Mark all that apply.)

___	English	___	Persian (Farsi)

___	French	___	Polish

___	Arabic	___	Portuguese

___	Chinese	___	Punjabi

___	Cree	___	Spanish

___	German	___	Tagalog (Filipino)

___	Greek	___	Ukrainian

___	Hungarian	___	Vietnamese

___	Italian	___	Other (Specify______)

___	Korean

SOCIO-Q6	What is the language that ... first learned at home in childhood and can still understand? (If ...(r/) can no longer understand the first language learned, choose the second language learned.)

(Do not read list. Mark all that apply.)

___	English	___	Persian (Farsi)

___	French	___	Polish

___	Arabic	___	Portuguese

___	Chinese	___	Punjabi

___	Cree	___	Spanish

___	German	___	Tagalog (Filipino)

___	Greek	___	Ukrainian

___	Hungarian	___	Vietnamese

___	Italian	___	Other (Specify______)

___	Korean

Race

SOCIO-Q7	How would you best describe ...(r/'s) race or colour?

(Do not read list. Mark all that apply.)

___	White (e.g. British, French, European, Latin/South American of European background)

___	Black

___	Korean

___	Filipino

___	Japanese

___	Chinese

___	Native/Aboriginal Peoples of North America

(North American Indian, Métis, Inuit/Eskimo)

___	(South Asian (e.g. Indian from India or Uganda, Pakistani, Punjabi, Tamil)

___	South East Asian (e.g. Vietnamese, Thai, Laotian)

___	West East Asian or North African (e.g. Armenian, Syrian, Moroccan)

___	Other (Specify ____________)

Education

EDUC-C1	If age<12, go to next section.

EDUC-Q1	Excluding kindergarten, how many years of elementary and high school have/has ... successfully completed?

(Do not read list. Mark one only.)

___	No schooling (Go to next section)

___	One to five years	___	Ten

___	Six	___	Eleven

___	Seven	___	Twelve

___	Eight	___	Thirteen

___	Nine

(If age < 15 then go to next section)

EDUC-Q2	Have/has ... graduated from high school?

___	Yes

___	No

EDUC-Q3	Have/has ... ever attended any other kind of school such as university, community college, business school, trade or vocational school, CEGEP or other post-secondary institution?

___	Yes

___	No	(Go to next section)

EDUC-Q4	What is the highest level of education that ... have/has attained?

(Do not read list. Mark one only.)

Note: categories have been put in reverse order

___	Some trade, technical, vocational school or business college

___	Some community college, CEGEP or nursing school

___	Some university

___	Diploma or certificate from trade, technical or vocational school, or business college

___	Diploma or certificate from community college, CEGEP, or nursing school)

___	Bachelor's or undergraduate degree or teacher's college (e.g., B.A., B.Sc., LL.B.)

___	Master's (e.g. M.A., M. Sc., M.Ed.)

___	Degree in medicine, dentistry, veterinary medicine or optometry (M.D., D.D.S., D.M.D., D.V.M., O.D.)

___	Earned doctorate (e.g. Ph.D., D.Sc., D.Ed.)

___	Other (Specify_____)

EDUC-C5	If age >= 65, go to next section.

EDUC-Q5	Are/Is ... currently attending a school, college or university?

___	Yes

___	No	(go to next section)

EDUC-Q6	Are/Is ... enrolled as a full-time or part-time student?

___	full-time

___	part-time

Labour Force

LFS-C1	If age<15 go to next section.

LFS-Q1	What do/does ... consider to be your/his/her current main activity? (For example, working for pay, caring for family.)

(Do not read list. Mark one only.)

___	Caring for family

___	Working for pay or profit

___	Caring for family and working for pay or profit

___	Going to school

___	Recovering from illness/on disability

___	Looking for work

___	Retired

___	Other (Specify)

LFS-I2	The next section contains questions about jobs or employment which ... have/has had during the past 12 months2. Please include such employment as part-time jobs, contract work, baby sitting and any other paid work.

LFS-C2	If LFS-Q1 = 2 or 3 ---> go to LFS-Q3.1

LFS-Q2	Have/has ... worked for pay or profit at any time in the past 12 months?

___	Yes

___	No	(go to LFS-Q17B)

LFS-C2A	If LFS-Q1=7 (retired) & LFS-Q2=2 (No) ---> go to next section.

Note:	Questions LFS-Q3 to LFS-Q11 are done as a roster allowing up to 6 jobs to be entered.

LFS-Q3.n	For whom/whom else have/has ... worked for pay or profit in the past 12 months?

_____________________ (50 chars)

LFS-Q4.n	Did ... have that job 1 year ago, that is, on %12MOSAGO%?

___	Yes	(Go to LFS-Q6.n)

___	No

LFS-Q5.n	When did ... start working at this job or business?

DD/MM/YY

LFS-Q6.n	Do/Does ... now have that job?

Yes	(Go to LFS-Q8.n)

No

LFS-Q7.n	When did ... stop working at this job or business?

DD/MM/YY

LFS-Q8.n	About how many hours per week do/does/did ... usually work at this job?

|_|_| HOURS

LFS-Q9.n	Which of the following best describes the hours ... usually work/works/worked at this job?

(Read list. Mark one only.)

___	Regular daytime schedule or shift

___	Regular evening shift

___	Regular night or graveyard shift

___	Rotating shift (change from days to evenings to nights)

___	Split shift

___	On call

___	Irregular schedule

___	Other (Specify_______)

LFS-Q10.n	Do/Does/Did ... usually work on weekends at this job?

___	Yes

___	No

LFS-Q11.n	Did ... do any other work for pay or profit in the past 12 months?

___	Yes

___	No

LFS-C12	If LFS-Q11.1 = No go to LFS-Q13.

LFS-Q12	Which was the main job?

(Answer will be chosen from roster of jobs.)

(Definition of main job will be supplied in the interviewers manual.)

LFS-Q13	Thinking about this/the main job, what kind of business, service or industry is this? (For example, wheat farm, trapping, road maintenance, retail shoe store, secondary school.)

_____________________ (50 chars)

LFS-Q14	Again, thinking about this/the main job, what kind of work was/were ... doing? (For example, medical lab technician, accounting clerk, secondary school teacher, supervisor of data entry unit, food processing labourer.)

_____________________ (50 chars)

LFS-Q15	In this work, what were ... r/'s most important duties or activities? (For example, analysis of blood samples, verifying invoices, teaching mathematics, organizing work schedules, cleaning vegetables.)

_____________________ (50 chars)

LFS-Q16	Did ... work mainly for others for wages or commission or in your/his/her own business, farm or practice?

(Do not read list. Mark one only.)

___	For others for wages, salary or commission

___	In own business, farm or professional practice

___	Unpaid family worker

LFS-C17	Check the calendar for gaps > 6 days.

If # gaps = 0 ---> go to LFS-C18

LFS-C17A	If any LFS-Q6 = 1 (currently employed) ---> go to LFS-Q17A

Otherwise ---> go to LFS-Q17B

LFS-Q17A	What was the reason that ... were/was not working for pay or profit during the most recent period away from work in the past year?

(Do not read list. Mark one only.)

___	Own illness or disability

___	Pregnancy

___	Caring for own children

___	Caring for elder relative(s)

___	Other personal or family responsibilities

___	School or educational leave

___	Labour dispute

___	Temporary layoff due to seasonal conditions

___	Temporary layoff - non-seasonal

___	Permanent layoff

___	Unpaid or partially paid vacation

___	Other (Specify________)

___	No period not working for pay or profit in the past year

GO TO LFS-C18

LFS-Q17B	What is the reason that ... are/is currently not working for pay or profit?

(Do not read list. Mark one only.)

___	Own illness or disability

___	Pregnancy

___	Caring for own children

___	Caring for elder relative(s)

___	Other personal or family responsibilities

___	School or educational leave

___	Labour dispute

___	Temporary layoff due to seasonal conditions

___	Temporary layoff - non-seasonal

___	Permanent layoff

___	Unpaid or partially paid vacation

___	Other (Specify_______)

___	No period not working for pay or profit in the past year

LFS-C18	If LFS-Q1 =2 or 3 then %LFS-WORK% =1;

Otherwise %LFS-WORK% =0;

Income

(Ask from knowledgeable person only)

INCOM-Q1	Thinking about your total household income, from which of the following sources did your household receive any income in the past 12 months?

(Read list. Mark all that apply.)

___	Wages and salaries

___	Income from self-employment

___	Dividends and interest on bonds, deposits and savings, stocks, mutual funds, etc.

___	Unemployment insurance

___	Worker's compensation

___	Benefits from Canada or Quebec Pension Plan

___	Retirement pensions, superannuation and annuities

___	Old Age Security and Guaranteed Income Supplement

___	Child Tax Benefit

___	Provincial or municipal social assistance or welfare

___	Child Support

___	Alimony

___	Other Income (eg. rental income, scholarships, other government income, etc.)

___	None	(Go to next section)

If more than one source of income is indicated ask INCOM-Q2.

Otherwise ask INCOM-Q3.

INCOM-Q2	What was the main source of income?

(Do not read list. Mark one only.)

___	Wages and salaries

___	Income from self-employment

___	Dividends and interest on bonds, deposits and savings, stocks, mutual funds, etc.

___	Unemployment insurance

___	Worker's compensation

___	Benefits from Canada or Quebec Pension Plan

___	Retirement pensions, superannuation and annuities

___	Old Age Security and Guaranteed Income Supplement

___	Child Tax Benefit

___	Provincial or Municipal Social Assistance or Welfare

___	Child Support

___	Alimony

___	Other Income (eg. rental income, scholarships, other government income, etc.)

INCOM-Q3	What is your best estimate of the total income before taxes and deductions of all household members from all sources in the past 12 months? Was the total household income:

___	Less than $20,000?

___	Less than $10,000?

___	Less than $5,000?	(go to next section)

___	$5,000 and more?	(go to next section)

___	$10,000 and more?

___	Less than $15,000?	(go to next section)

___	$15,000 and more?	(go to next section)

___	$20,000 and more?

___	Less than $40,000?

___	Less than $30,000?	(go to next section)

___	$30,000 and more?	(go to next section)

___	$40,000 and more?

___	Less than $50,000	(go to next section)

___	$50,000 to less than $60,000?	(go to next section)

___	$60,000 to less than $80,000?	(go to next section)

___	$80,000 and more?	(go to next section)

___	No income

Administration

H05-P1	Was this interview conducted on the telephone or in person?

___	On telephone

___	In person

___	Both (Specify in comments)

H05-P2	Record language of interview

English	Persian (Farsi)

French	Polish

Arabic	Portuguese

Chinese	Punjabi

Cree	Spanish

German	Tagalog (Filipino)

Greek	Ukrainian

Hungarian	Vietnamese

Italian	Other (Specify_______________)

Korean

Non-proxy Interview

(To be conducted for selected respondent only and age>=12)

(Proxy for those unable to answer due to special circumstances)

H06-P1	Who is providing the information for this person's form?

_______________________________

H06-INT	This part of the survey deals with various aspects of ... (r/'s) health. I'll be asking about such things as physical activity, social relationships, health status and stress. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being. I'll start with a few questions concerning ... (r/'s) health in general.

General Health

GENHLT-Q1	In general, would you say ... r/'s health is:

(Read list. Mark one only.)

___	Excellent?

___	Very good?

___	Good?

___	Fair?

___	Poor?

Check item: If sex = female & (age >= 15 & age <= 49) ask GENHLT-Q2. Otherwise go to next section.

GENHLT-Q2	It is important to know when analyzing health whether or not the person is pregnant. Are/Is ... pregnant?

___	Yes

___	No	(Go to next section)

GENHLT-Q3	Are/Is you/she planning to use the services of a physician, midwife or both?

(Do not read list. Mark one only.)

___	Physician only

___	Midwife only

___	Both physician and midwife

___	Neither

Height/Weight

HTWT-Q1	How tall are/is ... without shoes on?

___	feet	___	inches	OR	___	centimetres

HTWT-Q2	How much do/does you/he/she weigh?

___	pounds	OR	___	kilograms

Preventive Health Practices

(Non-proxy only)

PHP-Q1	When did you last have your blood pressure checked by a health professional?

(Do not read list. Mark one only.)

___	Less than 6 months ago

___	6 months to less than a year ago

___	1 year to less than 2 years ago

___	2 years to less than 5 years ago

___	5 years or more ago

___	Never

Former questions PHP-Q2, PHP-Q3b and PHP-Q4b (In what month was that?) have been deleted.

PHP-C2	If sex = female and age >= 35 then ask PHP-Q2.

If sex = female and age >= 16 and age < 35 then ask PHP-Q3.

If sex=male or females <=15 then go to next section.

PHP-Q2	Have you ever had a mammogram, that is, a breast X-ray?

___	Yes

___	No	(go to PHP-Q3)

PHP-Q2a	When was the last time?

(Do not read list. Mark one only.)

___	Less than 6 months ago

___	6 months to less than one year ago

___	1 year to less than 2 years ago

___	2 years or more ago

PHP-Q2b	Why did you have your last mammogram?

(Read list. Mark one only.)

___	Breast problem

___	Check-up, no particular problem

___	Other (specify_____________)

PHP-Q3	Have you ever had a PAP smear test?

___	Yes

___	No	(Go to next section)

PHP-Q3a	When was the last time?

(Do not read list. Mark one only.)

___	Less than 6 months ago

___	6 months to less than one year ago

___	1 year to less than 3 years ago

___	3 years to less than 5 years ago

___	5 years or more ago

Smoking

SMOK-INT	The next few questions are about smoking.

SMOK-Q1	Does anyone in this household smoke regularly inside the house?

___	Yes

___	No

SMOK-Q2	At the present time do/does ... smoke cigarettes daily, occasionally or not at all?

__	Daily

__	Occasionally	(go to SMOK-Q5)

__	Not at all	(go to SMOK-Q4a)

SMOK-Q3	At what age did you/he/she begin to smoke cigarettes daily?

__	Age

SMOK-Q4	How many cigarettes do/does you/he/she smoke each day now?

__	Number of cigarettes

(Go to next section)

SMOK-Q4a	Have/has you/he/she ever smoked cigarettes at all?

__	Yes

__	No	(Go to next section)

SMOK-Q5	Have/has you/he/she ever smoked cigarettes daily?

__	Yes

__	No	(Go to next section)

SMOK-Q6	At what age did you/he/she begin to smoke (cigarettes) daily?

__	Age

SMOK-Q7	How many cigarettes did you/he/she usually smoke each day?

__	Number of cigarettes

SMOK-Q8	At what age did you/he/she stop smoking (cigarettes) daily?

__	Age

Alcohol

ALCO-INT	Now, some questions about ... (r/'s) alcohol consumption. When we use the word drink it means:

- one bottle or can of beer or a glass of draft

- one glass of wine or a wine cooler

- one straight or mixed drink with one and a half ounces of hard liquor.

ALCO-Q1	During the past 12 months2, have/has ... had a drink of beer, wine, liquor or any other alcoholic beverage?

__	Yes

__	No	(Go to ALCO-Q6)

ALCO-Q2	During the past 12 months, how often did you/he/she drink alcoholic beverages?

(Do not read list. Mark one only.)

__	Every day

__	4-6 times a week

__	2-3 times a week

__	Once a week

__	2-3 times a month

__	Once a month

__	Less than once a month

ALCO-Q3	How many times in the past 12 months have/has you/he/she had 5 or more drinks on one occasion?

___	Number of times

If PROXY=yes then go to ALCO-Q5

ALCO-Q4	In the past 12 months, what is the highest number of drinks you had on one occasion?

___	Number of drinks

ALCO-Q5	Thinking back over the past week, that is, from %1WKAGO% to yesterday, did ... have a drink of beer, wine, liquor or any other alcoholic beverage?

___	Yes

___	No (Go to next section)

ALCO-Q5A	Starting with yesterday, how many drinks did ... have on:

___	Monday?

___	Tuesday?

___	Wednesday?

___	Thursday?

___	Friday?

___	Saturday?

___	Sunday?

(Go to next section)

ALCO-Q6	Did you/he/she ever regularly drink more than 12 drinks a week?

___	Yes

___	No	(Go to next section)

ALCO-Q7	Why did you/he/she reduce or quit drinking altogether?

(Do not read list. Mark all that apply.)

___	Dieting

___	Athletic training

___	Pregnancy

___	Getting older

___	Drinking too much/drinking problem

___	Affected work, studies, employment opportunities

___	Interfered with family or home life

___	Affected physical health

___	Affected friendships or social relationships

___	Affected financial position

___	Affected outlook on life, happiness

___	Because of influence of family or friends

___	Other (specify______________)

Physical Activities

(Non-proxy only)

PHYS-INTa	Now I'd like to ask you about some of your physical activities. To begin with, I'll be dealing with physical activities not related to work, that is, leisure time activities.

PHYS-Q1	Have you done any of the following in the past 3 months?

(Read list. Mark all that apply.)

___	Walking for exercise	___	Cross-country skiing

___	Gardening, yard work	___	Bowling

___	Swimming	___	Baseball/softball

___	Bicycling	___	Tennis

___	Popular or social dance	___	Weight-training

___	Home exercises	___	Fishing

___	Ice hockey	___	Volleyball

___	Skating	___	Yoga or tai-chi

___	Downhill skiing	___	Other (specify)

___	Jogging/running	___	Other (specify)

___	Golfing	___	Other (specify)

___	Exercise class/aerobics	___	None

For each response ask PHYS-Q2 to PHYS-Q3.

If "none" go to PHYS-INTb.

PHYS-Q2	In the past 3 months, how many times did you participate in %ACTIVITY%?

___	Number of times

PHYS-Q3	About how much time did you usually spend on each occasion?

(Do not read list. Mark one only.)

___	1 to 15 minutes

___	16 to 30 minutes

___	31 to 60 minutes

___	More than one hour

PHYS-INTb	Next, some questions about the amount of time you spent in the past 3 months on physical activity at work or while doing daily chores around the house, but not leisure time activity.

PHYS-Q4a	In a typical week in the past 3 months, how many hours did you usually spend walking to work or to school or while doing errands?

(Do not read list. Mark one only.)

___	None

___	Less than 1 hour

___	From 1 to 5 hours

___	From 6 to 10 hours

___	From 11 to 20 hours

___	More than 20 hours

PHYS-Q4b	In a typical week, how much time did you usually spend bicycling to work or to school or while doing errands?

(Do not read list. Mark one only.)

___	None

___	Less than 1 hour

___	From 1 to 5 hours

___	From 6 to 10 hours

___	From 11 to 20 hours

___	More than 20 hours

PHYS-C1	If Bicycling was indicated as an activity in PHYS-Q1 or not a "none" in PHYS-Q4b, ask PHYS-Q5. Otherwise go to PHYS-Q6.

PHYS-Q5	When riding a bicycle how often did you wear a helmet?

(Read list. Mark one only.)

___	Always

___	Most of the time

___	Rarely

___	Never

PHYS-Q6	Thinking back over the past 3 months, which of the following best describes your usual daily activities or work habits?

(Read list. Mark one only.)

___	Usually sit during day and do not walk about very much

___	Stand or walk about quite a lot during the day but do not have to carry or lift things very often

___	Usually lift or carry light loads, or have to climb stairs or hills often

___	Do heavy work or carry very heavy loads

Injuries

INJ-INT	Now some questions about any injuries, which occurred in the past 12 months2, that were serious enough to limit ... (r/'s) normal activities. For example, a broken bone, a bad cut or burn, a sore back or sprained ankle, or a poisoning.

INJ-Q1	In the past 12 months, did ... have any injuries that were serious enough to limit your/his/her normal activities?

___	Yes

___	No	(Go to next section)

INJ-Q2	How many times were/was you/he/she injured?

___	times

INJ-Q3	Thinking about the most serious injury, what type of injury did you/he/she have? For example, a broken bone or burn.

(Do not read list. Mark one only.)

___	Multiple injuries

___	Broken or fractured bones

___	Burn or scald

___	Dislocation

___	Sprain or strain

___	Cut or scrape

___	Bruise or abrasion

___	Concussion

___	Poisoning by substance or liquid

___	Internal injury

___	Other (specify________________)

INJ-Q4	What part of your/his/her body was injured?

(Do not read list. Mark one only.)

___	Multiple sites

___	Eyes

___	Head (excluding eyes)

___	Neck

___	Shoulder

___	Arms or hands

___	Hip

___	Legs or feet

___	Back or spine

___	Trunk (excluding back or spine) (including chest, internal organs, etc.)

INJ-Q5	Where did the injury happen?

(Do not read list. Mark one only.)

___	Home and surrounding area

___	Farm

___	Place for recreation or sport

(e.g. golf course, basketball court, playground (including school))

___	Street or highway

___	Building used by general public (e.g. hotel, shopping plaza, restaurant, office building, school)

___	Residential institution (e.g. hospital, jail, etc.)

___	Mine

___	Industrial place or premise (e.g. dockyard)

___	Other (specify _______________)

INJ-Q6	What happened? For example, was the injury the result of a fall, motor vehicle accident, a physical assault etc.?

(Do not read list. Mark one only.)

___	Motor vehicle accident

___	Accidental fall

___	Fire, flames or resulting fumes

___	Accidentally struck by an object/person

___	Physical assault

___	Suicide attempt

___	Accidental injury caused by explosion

___	Accidental injury caused by natural/environmental factors (e.g. weather conditions, Poison ivy, animal bites, stings)

___	Accidental drowning or submersion

___	Accidental suffocation

___	Hot or corrosive liquids, foods or substances

___	Accident caused by machinery (e.g. farm machinery, forklift, woodworking machinery)

___	Accident caused by cutting and piercing instruments or objects (lawnmower, knife, stapler)

___	Accidental poisoning

___	Other (specify__________________)

INJ-Q7	Was this a work-related injury?

___	Yes

___	No

INJ-Q8	We would like to know what precautions ... are/is taking, if any, to prevent this kind of injury from happening again. What precautions are/is you/he/she taking?

(Do not read list. Mark all that apply.)

___	Gave up the activity

___	Being more careful

___	Took safety training

___	Increased supervision of child

___	Using protective gear/safety equipment (e.g. bike helmet, car safety restraint, etc.)

___	Changing physical situation (e.g. removing rugs, storing medications out of reach, safety gates, etc.)

___	Other (specify)

___	No precautions

Stress

(Age >= 18 and non-proxy only)

Ongoing Problems

STRESS-INT	The next portion of the questionnaire deals with different kinds of stress. Although the questions may seem repetitive, they are related to various aspects of a person's physical, emotional and mental health.

CSTRESS-INT	I'll start by describing situations that sometimes come up in people's lives. As there are no right or wrong answers, the idea is to choose the answer best suited to your personal situation. I'd like you to tell me if these things are true for you at this time by answering "true" if it applies to you now or "false" if it does not.

CSTRESS-Q1	You are trying to take on too many things at once.

___	True

___	False

CSTRESS-Q2	There is too much pressure on you to be like other people.

___	True

___	False

CSTRESS-Q3	Too much is expected of you by others.

___	True

___	False

CSTRESS-Q4	You don't have enough money to buy the things you need.

___	True

___	False

If marital status =married or living with a partner or common-law go to CSTRESS-Q5.

If marital status=single,widowed, separated or divorced go to CSTRESS-Q8.

Otherwise (i.e. marital status is unknown) go to CSTRESS-Q9.

CSTRESS-Q5	Your partner doesn't understand you.

___	True

___	False

CSTRESS-Q6	Your partner doesn't show enough affection.

___	True

___	False

CSTRESS-Q7	Your partner is not committed enough to your relationship.

___	True

___	False

Go to CSTRESS-Q9

CSTRESS-Q8	You find it is very difficult to find someone compatible with you.

___	True

___	False

CSTRESS-Q9	Do you have any children?

___	Yes

___	No	(Go to CSTRESS-Q12)

CSTRESS-Q10	Remember I want to know if you feel any of these statements are true for you at this time.

One of your children seems very unhappy.

___	True

___	False

CSTRESS-Q11	A child's behaviour is a source of serious concern to you.

___	True

___	False

CSTRESS-Q12	Your work around the home is not appreciated.

___	True

___	False

CSTRESS-Q13	Your friends are a bad influence.

___	True

___	False

CSTRESS-Q14	You would like to move but you cannot.

___	True

___	False

CSTRESS-Q15	Your neighbourhood or community is too noisy or too polluted.

___	True

___	False

CSTRESS-Q16	You have a parent, a child or partner who is in very bad health and may die.

___	True

___	False

CSTRESS-Q17	Someone in your family has an alcohol or drug problem.

___	True

___	False

CSTRESS-Q18	People are too critical of you or what you do.

___	True

___	False

Recent Life Events

RECENT-INTa	Now I'd like to ask you about some things that may have happened in the past 12 months2. Some of these experiences happen to most people at one time or another, while some happen to only a few. First, I'd like to ask about yourself or anyone close to you (that is, your spouse or partner, children, relatives or close friends).

RECENT-Q1	In the past 12 months, was any one of you beaten up or physically attacked?

___	Yes

___	No

RECENT-INTb	Now I'd like you to think just about your family, (that is, yourself and your spouse/partner or children, if any).

RECENT-Q2	In the past 12 months, did you or someone in your family, have an unwanted pregnancy?

___	Yes

___	No

RECENT-Q3	In the past 12 months, did you or someone in your family have an abortion or miscarriage?

___	Yes

___	No

RECENT-Q4	In the past 12 months, did you or someone in your family have a major financial crisis?

___	Yes

___	No

RECENT-Q5	In the past 12 months, did you or someone in your family fail school or a training program?

___	Yes

___	No

RECENT-INTc	Now I'd like you to think just about yourself and your spouse or partner.

If marital status = married/living together/common-law include the phrase "or your partner" in the RECENT-Q6 and RECENT-Q7.

RECENT-Q6	In the past 12 months, did you (or your partner) experience a change of job for a worse one?

___	Yes

___	No

RECENT-Q7	In the past 12 months, were you (or your partner) demoted at work or did you/either of you take a cut in pay?

___	Yes

___	No

If marital status = married/living together/common-law ask RECENT-Q8.

Otherwise go to RECENT-Q9.

RECENT-Q8	In the past 12 months, did you have increased arguments with your partner?

___	Yes

___	No

RECENT-Q9	Now, just you personally, in the past 12 months, did you go on Welfare?

___	Yes

___	No

IF CSTRESS-Q9 = yes (have children) ask RECENT-Q10.

Otherwise go to next section.

RECENT-Q10	In the past 12 months, did you have a child move back into the house?

___	Yes

___	No

Childhood and adult stressors("traumas")

TRAUM-INTa	The next few questions ask about some things that may have happened to you while you were a child or a teenager, before you moved out of the house. Please tell me if any of these things have happened.

TRAUM-Q1	Did you spend 2 weeks or more in the hospital?

___	Yes

___	No

TRAUM-Q2	Did your parents get a divorce?

___	Yes

___	No

TRAUM-Q3	Did your father or mother not have a job for a long time when they wanted to be working?

___	Yes

___	No

TRAUM-Q4	Did something happen that scared you so much you thought about it for years after?

___	Yes

___	No

TRAUM-Q5	Were you sent away from home because you did something wrong?

___	Yes

___	No

TRAUM-Q6	Did either of your parents drink or use drugs so often that it caused problems for the family?

___	Yes

___	No

TRAUM-Q7	Were you ever physically abused by someone close to you?

___	Yes

___	No

Work Stress

(Age >= 15 and non-proxy only)

Check item: ask only of those currently employed. If more than one job is held ask for the main job.

WSTRESS-Q1	Now I'm going to read you a series of statements that might describe your job situation. Please tell me if you STRONGLY AGREE, AGREE, NEITHER AGREE NOR DISAGREE, DISAGREE, or STRONGLY DISAGREE with each of the following:

a)	Your job requires that you learn new things

b)	Your job requires a high level of skill

c)	Your job allows you freedom to decide how you do your job

d)	Your job requires that you do things over and over

e)	Your job is very hectic

f)	You are free from conflicting demands that others make

g)	Your job security is good

h)	Your job requires a lot of physical effort

i)	You have a lot to say about what happens in your job

j)	You are exposed to hostility or conflict from the people you work with

k)	Your supervisor is helpful in getting the job done

l)	The people you work with are helpful in getting the job done

WSTRESS-Q2	How satisfied are you with your job?

(Read list. Mark one only.)

___	Very satisfied

___	Somewhat satisfied

___	Not too satisfied

___	Not at all satisfied

Self-Esteem and Mastery

(Age >= 12 and non-proxy only)

ESTMAST-INT	Now, I am going to read you a series of statements that people might use to describe themselves. Please tell me if you STRONGLY AGREE, AGREE, NEITHER AGREE NOR DISAGREE, DISAGREE or STRONGLY DISAGRE with each of the following:

ESTEEM-Q1	a)	You feel that you have a number of good qualities.

b)	You feel that you're a person of worth at least equal to others.

c)	You are able to do things as well as most other people.

d)	You take a positive attitude toward yourself.

e)	On the whole you are satisfied with yourself.

f)	All in all, you're inclined to feel you're a failure.

MAST-Q1	a)	You have little control over the things that happen to you.

b)	There is really no way you can solve some of the problems you have.

c)	There is little you can do to change many of the important things in your life.

d)	You often feel helpless in dealing with problems of life.

e)	Sometimes you feel that you are being pushed around in life.

f)	What happens to you in the future mostly depends on you.

g)	You can do just about anything you really set your mind to.

Sense of Coherence

(Age>=18 and non-proxy only.)

SCOH-INT	Next is a series of questions relating to various aspects of people's lives. For each question please answer with a number between 1 and 7. Take your time to think about each question before answering.

SCOH-Q1	In this first question 1 means very seldom or never and 7 means very often. How often do you have the feeling that you don't really care about what goes on around you?

1	Very seldom or never

2

3	|

4	|

5	|

6

7	Very often

SCOH-Q2	In this question 1 that means it has never happened and 7 means it has always happened. How often in the past were you surprised by the behaviour of people whom you thought you knew well?

1	Never happened

2

3	|

4	|

5	|

6

7	Always happened

SCOH-Q3	In this question 1 means that it has never happened and 7 means it has always happened. How often have people you counted on disappointed you?

1	Never happened

2

3	|

4	|

5	|

6

7	Always happened

SCOH-Q4	In this question 1 means very often and 7 means very seldom or never. How often do you have the feeling you're being treated unfairly?

1	Very often

2

3	|

4	|

5	|

6

7	Very seldom or never

SCOH-Q5	In this question 1 means very often and 7 means very seldom or never. How often do you have the feeling you are in an unfamiliar situation and don't know what to do?

1	Very often

2

3	|

4	|

5	|

6

7	Very seldom or never

SCOH-Q6	In this question 1 means very often and 7 means very seldom or never. How often do you have very mixed-up feelings and ideas?

1	Very often

2

3	|

4	|

5	|

6

7	Very seldom or never

SCOH-Q7	In this question 1 means very often and 7 means very seldom or never. how often do you have feelings inside that you would rather not feel?

1	Very often

2

3	|

4	|

5	|

6

7	Very seldom or never

SCOH-Q8	In this question 1 means very seldom or never and 7 means very often. Many people -- even those with a strong character -- sometimes feel like sad sacks (losers) in certain situations. How often have you felt this way in the past?

1	Very seldom or never

2

3	|

4	|

5	|

6

7	Very often

SCOH-Q9	In this question 1 means very often and 7 means very seldom or never. How often do you have the feeling that there's little meaning in the things you do in your daily life?

1	Very often

2

3

4

5

6

7	Very seldom or never

SCOH-Q10	In this question 1 means very often and 7 means very seldom or never. How often do you have feelings that you're not sure you can keep under control?

1	Very often

2

3

4

5

6

7	Very seldom or never

SCOH-Q11	In this question 1 means no clear goals or purpose and 7 means very clear goals and purpose. Until now your life has had no clear goals or purpose or has it had very clear goals and purpose?

1	No clear goals or no purpose at all

2

3	|

4	|

5	|

6

7	Very clear goals and purpose

SCOH-Q12	In this question 1 means you overestimate or underestimate importance and 7 means you see things in the right proportion. When something happens, you generally find that you overestimate or underestimate its importance or you see things in the right proportion?

1	Overestimate or underestimate its importance

2

3	|

4	|

5	|

6

7	See things in the right proportion

SCOH-Q13	In this question 1 means a source of great pleasure and satisfaction and 7 means a source of pain and boredom. Is doing the things you do every day a source of great pleasure and satisfaction or a source of pain and boredom?

1	A great deal of pleasure and satisfaction

2

3	|

4	|

5	|

6

7	A source of pain and boredom

Health Status

HSTAT-INT	The next set of questions ask about ... (r/'s) day to day health. The questions are not about illnesses like colds that affect people for short periods of time. They are concerned with a person's usual abilities. You may feel that some of these questions do not apply to you/him/her, but it is important that we ask the same questions of everyone.

Vision

HSTAT-Q1	Are/Is ... usually able to see well enough to read ordinary newsprint without glasses or contact lenses?

___	Yes	(Go to HSTAT-Q4)

___	No

HSTAT-Q2	Are/Is you/he/she usually able to see well enough to read ordinary newsprint with glasses or contact lenses?

___	Yes	(Go to HSTAT-Q4)

___	No

HSTAT-Q3	Are/Is you/he/she able to see at all?

___	Yes

___	No	(Go to HSTAT-Q6)

HSTAT-Q4	Are/Is you/he/she able to see well enough to recognize a friend on the other side of the street without glasses or contact lenses ?

___	Yes	(Go to HSTAT-Q6)

___	No

HSTAT-Q5	Are/Is you/he/she usually able to see well enough to recognize a friend on the other side of the street with glasses or contact lenses?

___	Yes

___	No

Hearing

HSTAT-Q6	Are/Is ... usually able to hear what is said in a group conversation with at least three other people without a hearing aid?

___	Yes	(Go to HSTAT-Q10)

___	No

HSTAT-Q7	Are/Is you/he/she usually able to hear what is said in a group conversation with at least three other people with a hearing aid?

___	Yes	(Go to HSTAT-Q8)

___	No

HSTAT-Q7a	Are/Is you/he/she able to hear at all?

___	Yes

___	No	(Go to HSTAT-Q10)

HSTAT-Q8	Are/Is you/he/she usually able to hear what is said in a conversation with one other person in a quiet room without a hearing aid ?

___	Yes	(Go to HSTAT-Q10)

___	No

HSTAT-Q9	Are/Is you/he/she usually able to hear what is said in a conversation with one other person in a quiet room with a hearing aid?

___	Yes

___	No

Speech

HSTAT-Q10	Are/Is ... usually able to be understood completely when speaking with strangers in your own language?

___	Yes	(Go to HSTAT-Q14)

___	No

HSTAT-Q11	Are/Is you/he/she able to be understood partially when speaking with strangers?

___	Yes

___	No

HSTAT-Q12	Are/Is you/he/she able to be understood completely when speaking with those who know you/him/her well?

___	Yes	(Go to HSTAT-Q14)

___	No

HSTAT-Q13	Are/Is you/he/she able to be understood partially when speaking with those who know you/him/her well?

___	Yes

___	No

Getting Around

HSTAT-Q14	Are/Is ... usually able to walk around the neighbourhood without difficulty and without mechanical support such as braces, a cane or crutches?

___	Yes	(Go to HSTAT-Q21)

___	No

HSTAT-Q15	Are/Is you/he/she able to walk at all?

___	Yes

___	No	(Go to HSTAT-Q18)

HSTAT-Q16	Do/Does you/he/she require mechanical support such as braces, a cane or crutches to be able to walk around the neighbourhood?

___	Yes

___	No

HSTAT-Q17	Do/Does you/he/she require the help of another person to be able to walk?

___	Yes

___	No

HSTAT-Q18	Do/Does you/he/she require a wheelchair to get around?

___	Yes

___	No	(Go to HSTAT-Q21)

HSTAT-Q19	How often do/does you/he/she use a wheelchair?

(Read list. Mark one only.)

___	Always

___	Often

___	Sometimes

___	Never

HSTAT-Q20	Do/Does you/he/she need the help of another person to get around in the wheelchair?

___	Yes

___	No

Hands and Fingers

HSTAT-Q21	Are/Is ... usually able to grasp and handle small objects such as a pencil and scissors?

___	Yes	(Go to HSTAT-Q25)

___	No

HSTAT-Q22	Do/Does you/he/she require the help of another person because of limitations in the use of hands or fingers?

___	Yes

___	No	(Go to HSTAT-Q24)

HSTAT-Q23	Do/Does you/he/she require the help of another person with:

(Read list. Mark one only.)

___	Some tasks?

___	Most tasks?

___	Almost all tasks?

___	All tasks?

HSTAT-Q24	Do/Does you/he/she require special equipment, for example, devices to assist in dressing because of limitations in the use of hands or fingers?

___	Yes

___	No

Feelings

HSTAT-Q25	Would you describe yourself/... as being usually:

(Read list. Mark one only.)

___	Happy and interested in life?

___	Somewhat happy?

___	Somewhat unhappy?

___	Unhappy with little interest in life?

___	So unhappy that life is not worthwhile?

Memory

HSTAT-Q26	How would you describe your/his/her usual ability to remember things? Are/Is you/he/she:

(Read list. Mark one only.)

___	Able to remember most things?

___	Somewhat forgetful?

___	Very forgetful?

___	Unable to remember anything at all?

Thinking

HSTAT-Q27	How would you describe your/his/her usual ability to think and solve day to day problems? Are/Is you/he/she:

(Read list. Mark one only.)

___	Able to think clearly and solve problems?

___	Having a little difficulty?

___	Having some difficulty?

___	Having a great deal of difficulty?

___	Unable to think or solve problems?

Pain and Discomfort

HSTAT-Q28	Are/Is ... usually free of pain or discomfort?

___	Yes	(Go to next section)

___	No

HSTAT-Q29	How would you describe the usual intensity of your/his/her pain or discomfort?

(Read list. Mark one only.)

___	Mild

___	Moderate

___	Severe

HSTAT-Q30	How many activities does your/his/her pain or discomfort prevent?

(Read list. Mark one only.)

___	None

___	A few

___	Some

___	Most

Drug Use

DRUG-INT	Now I'd like to ask a few questions about ... (r/'s) use of medications, both prescription and over-the- counter as well as other health products.

DRUG-Q1	In the past month, did ... take any of the following medications?

(Read list. Mark all that apply.)

___	Pain relievers such as aspirin or tylenol (includes arthritis medicine and anti-inflammatories)

___	Tranquilizers such as valium

___	Diet pills

___	Anti-depressants

___	Codeine, Demerol or Morphine

___	Allergy medicine such as "Sinutab"

___	Asthma medications

___	Cough or cold remedies

___	Penicillin or other antibiotic

___	Medicine for the heart

___	Medicine for blood pressure

___	Diuretics or water pills

___	Steroids

___	Insulin

___	Pills to control diabetes

___	Sleeping pills

___	Stomach remedies

___	Laxatives

___	Hormones for menopause or aging symptoms (check item: sex=female, age >= 30)

___	Birth control pills (check item: sex=female, age >= 12 & age <= 49)

___	Any other medication (Specify_________)

___	None of the above

DRUG-C1	If any drug(s) specified in DRUG-Q1 go to DRUG-Q2. Otherwise go to DRUG-Q4.

DRUG-Q2	Now, I am referring to yesterday and the day before yesterday. During those two days, how many different medications did you/he/she take?

___	Number of different medications

If number=0 then go to DRUG-Q4

For each number >0 ask DRUG-Q3...up to a maximum of 12.

DRUG-Q3	What is the exact name of the medication that ... took? (Ask the person to look at the bottle, tube or box.)

____________________________

DRUG-Q4	There are many other health products such as ointments, vitamins, herbs, minerals, teas or protein drinks which people use to prevent illness or to improve or maintain their health. Do/Does ... use any of these or other health products?

___	Yes

___	No	(Go to next section)

DRUG-Q5	What is the exact name of the health product that ... use(s)? (Ask the person to look at the bottle, tube or box.) (up to 12 products)

____________________________

Mental Health

(Non-proxy only)

Note: former questions MHLTH-Q1a to Q1i have been replaced by this 6-item scale.

MHLTH-INTa	Now some questions about mental and emotional well-being. During the past month4, about how often did you feel:

MHLTH-Q1a	... so sad that nothing could cheer you up?

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-Q1b	... nervous?

(Read list. Mark one only.)

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-Q1c	... restless or fidgety?

(Read list. Mark one only.)

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-Q1d	... hopeless?

(Read list. Mark one only.)

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-Q1e	... worthless?

(Read list. Mark one only.)

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-Q1f	During the past month, about how often did you feel that everything was an effort?

(Read list. Mark one only.)

___	All of the time

___	Most of the time

___	Some of the time

___	A little of the time

___	None of the time

MHLTH-C1g	IF MHLTH-Q1a to MHLTH-Q1f are all "none" go to MHLTH-Q1k.

MHLTH-Q1g	We have just been talking about feelings and experiences that occurred to different degrees during the past month. Taking them altogether, did these feelings occur more often in the past month than is usual for you, less often than usual , or about the same as usual?

(Do not read list. Mark one only.)

___	More often

___	Less often	(Go to MHLTH-Q1i)

___	About the same	(Go to MHLTH-Q1j)

___	Never have had any	(Go to MHLTH-Q1k)

MHLTH-Q1h	Is that a lot more, somewhat or only a little more often than usual?

(Do not read list. Mark one only.)

___	A lot more

___	Somewhat more

___	A little more

(Go to Q1j)

MHLTH-Q1i	Is that a lot less, somewhat or only a little less often than usual?

(Do not read list. Mark one only.)

___	A lot less

___	Somewhat less

___	A little less

MHLTH-Q1j	How much do these experiences usually interfere with your life or activities?

(Read list. Mark one only.)

___	A lot

___	Some

___	A little

___	Not at all

MHLTH-Q1k	In the past 12 months2, have you seen or talked on the telephone to a health professional about your emotional or mental health?

___	Yes

___	No	(Go to MHLTH-Q2.)

MHLTH-Q1l	How many times (in the past 12 months)?

___	# of times

Note: former questions MHLTH-Q1m , MHLTH-Q1n and MHLTH-INTb were deleted.

MHLTH-Q2	During the past 12 months, was there ever a time when you felt sad, blue, or depressed for 2 weeks or more in a row?

___	Yes

___	No	(Go to MHLTH-Q16.)

MHLTH-Q3	For the next few questions, please think of the 2-week period during the past 12 months when these feelings were worst. During that time how long did these feelings usually last?

(Read list. Mark one only.)

___	All day long

___	Most of the day

___	About half of the day	(Go to MHLTH-Q16.)

___	Less than half the day	(Go to MHLTH-Q16.)

MHLTH-Q4	How often did you feel this way during those 2 weeks?

(Read list. Mark one only.)

___	Every day

___	Almost every day

___	Less often	(Go to MHLTH-Q16.)

MHLTH-Q5	During those 2 weeks did you lose interest in most things?

___	Yes	(KEY PHRASE = LOSING INTEREST)

___	No

MHLTH-Q6	Did you feel tired out or low on energy all of the time?

___	Yes	(KEY PHRASE = FEELING TIRED)

___	No

MHLTH-Q7	Did you gain weight, lose weight or stay about the same?

(Do not read list. Mark one only.)

___	Gained weight	(KEY PHRASE = GAINING WEIGHT)

___	Lost weight	(KEY PHRASE = LOSING WEIGHT)

___	Stayed about the same	(Go to MHLTH-Q9.)

___	Was on a diet	(Go to MHLTH-Q9.)

MHLTH-Q8	About how much did you (gain/lose)?

___	pounds or kilograms

MHLTH-Q9	Did you have more trouble falling asleep than you usually do?

___	Yes	(KEY PHRASE = TROUBLE FALLING ASLEEP)

___	No	(Go to MHLTH-Q11.)

MHLTH-Q10	How often did that happen?

(Read list. Mark one only.)

___	Every night

___	Nearly every night

___	Less often

MHLTH-Q11	Did you have a lot more trouble concentrating than usual?

___	Yes	(KEY PHRASE = TROUBLE CONCENTRATING)

___	No

MHLTH-Q12	At these times, people sometimes feel down on themselves, no good, or worthless. Did you feel this way?

___	Yes	(KEY PHRASE = FEELING DOWN ON YOURSELF)

___	No

MHLTH-Q13	Did you think a lot about death - either your own, someone else's, or death in general?

___	Yes	(KEY PHRASE =THOUGHTS ABOUT DEATH)

___	No

MHLTH-C14	If any "yes" in Q5, Q6, Q9, Q11, Q12 or Q13, or Q7 is "gain" or "lose" then go to MHLTH-Q14.

Otherwise go to next section.

MHLTH-Q14	Reviewing what you just told me, you had 2 weeks in a row during the past 12 months when you were sad, blue, or depressed and also had some other things like (KEY PHRASES). About how many weeks altogether did you feel this way during the past 12 months?

___	# of weeks (IF >51 weeks then go to next section.)

MHLTH-Q15	Think about the last time you felt this way for 2 weeks or more in a row. In what month was that?

___	January	___	July

___	February	___	August

___	March	___	September

___	April	___	October

___	May	___	November

___	June	___	December

Go to next section.

MHLTH-Q16	During the past 12 months, was there ever a time lasting 2 weeks or more when you lost interest in most things like hobbies, work, or activities that usually give you pleasure?

___	Yes

___	No	(Go to next section)

MHLTH-Q17	For the next few questions, please think of the 2-week period during the past 12 months when you had the most complete loss of interest in things. During that 2-week period, how long did the loss of interest usually last?

(Read list. Mark one only.)

___	All day long

___	Most of the day

___	About half of the day	(Go to next section)

___	Less than half the day	(Go to next section)

MHLTH-Q18	How often did you feel this way during those 2 weeks?

(Read list. Mark one only.)

___	Every day

___	Almost every day

___	Less often	(Go to next section)

MHLTH-Q19	During those 2 weeks did you feel tired out or low on energy all the time?

___	Yes	(KEY PHRASE = FEELING TIRED)

___	No

MHLTH-Q20	Did you gain weight, lose weight, or stay about the same?

(Do not read list. Mark one only.)

___	Gained weight	(KEY PHRASE = GAINING WEIGHT)

___	Lost weight	(KEY PHRASE = LOSING WEIGHT)

___	Stayed about the same	(Go to MHLTH-Q22.)

___	Was on a diet	(Go to MHLTH-Q22.)

MHLTH-Q21	About how much did you (gain/lose)?

___	pounds or kilograms

MHLTH-Q22	Did you have more trouble falling asleep than you usually do?

___	Yes	(KEY PHRASE = TROUBLE FALLING ASLEEP)

___	No	(Go to MHLTH-Q24)

MHLTH-Q23	How often did that happen during those 2 weeks?

(Read list. Mark one only.)

___	Every night

___	Nearly every night

___	Less often

MHLTH-Q24	Did you have a lot more trouble concentrating than usual?

___	Yes	(KEY PHRASE = TROUBLE CONCENTRATING)

___	No

MHLTH-Q25	At these times, people sometimes feel down on themselves, no good, or worthless. Did you feel this way?

___	Yes	(KEY PHRASE = FEELING DOWN ON YOURSELF)

___	No

MHLTH-Q26	Did you think a lot about death - either your own, someone else's, or death in general?

___	Yes	(KEY PHRASE =THOUGHTS ABOUT DEATH)

___	No

MHLTH-C27	If any "yes" in Q19, Q22, Q24, Q25 or Q26, or Q20 is "gain" or "lose" then go to MHLTH-Q27.

Otherwise go to next section.

MHLTH-Q27	Reviewing what you just told me, you had 2 weeks in a row during the past 12 months when you lost interest in most things and also had some other things like (KEY PHRASES). About how many weeks did you feel this way during the past 12 months?

___	# of weeks (IF >51 weeks then go to next section.)

MHLTH-Q28	Think about the last time you had 2 weeks in a row when you felt this way. In what month was that?

___	January	___	July

___	February	___	August

___	March	___	September

___	April	___	October

___	May	___	November

___	June	___	December

Social Support

(Non-proxy only)

SOCSUP-INT	Now, a few questions about your contact with different groups and support from family and friends.

SOCSUP-Q1	Are you a member of any voluntary organizations or associations such as school groups, church social groups, community centres, ethnic associations or social, civic or fraternal clubs?

___	Yes

___	No	(Go to SOCSUP-Q2a)

SOCSUP-Q2	How often did you participate in meetings or activities sponsored by these groups in the past 12 months? If you belong to many, just think of the ones in which you are most active.

(Read list. Mark one only.)

___	At least once a week

___	At least once a month

___	At least 3 or 4 times a year

___	At least once a year

___	Not at all

SOCSUP-Q2a	Other than on special occasions (such as weddings, funerals or baptisms), how often did you attend religious services or religious meetings in the past 12 months?

(Read list. Mark one only.)

___	At least once a week

___	At least once a month

___	At least 3 or 4 times a year

___	At least once a year

___	Not at all

SOCSUP-Q3	Do you have someone you can confide in, or talk to about your private feelings or concerns?

___	Yes

___	No

SOCSUP-Q4	Do you have someone you can really count on to help you out in a crisis situation?

___	Yes

___	No

SOCSUP-Q5	Do you have someone you can really count on to give you advice when you are making important personal decisions?

___	Yes

___	No

SOCSUP-Q6	Do you have someone that makes you feel loved and cared for?

___	Yes

___	No

SOCSUP-Q7	The next few questions are about your contact in the past 12 months with persons who do not live with you either in person, by phone, or by mail. If you have more than one person in a category, for example, several sisters, think of the one with whom you have the most contact. How often did you have contact with [fill with categories below]?

___	Your parents or parents-in-law

___	Your grandparents

___	Your daughters or daughters-in-law

___	Your sons or sons-in-law

___	Your brothers or sisters

___	Other relatives (including in-laws)

___	Your close friends

___	Your neighbours

Choice of responses are:	(Read list. Mark one only.)

Don't have any

Every day

At least once a week

2 or 3 times a month

Once a month

A few times a year

Once a year

Never

Health Number

H06-HLTH#	We are seeking your permission to link information collected during this interview with provincial health information. This would include information on past and continuing use of services such as visits to hospitals, clinics, physician's offices or other services provided by the province. This information will be used for statistical purposes only. Do we have your permission?

___	Yes

___	No (Go to H06-SHARE)

H06-HLTH#l	Having a provincial health number will assist us in linking to this other information. What is ...r/s provincial health number?

____________

Agreement to Share

H06-SHARE	To avoid duplication Statistics Canada intends to share the information from this survey with provincial ministries of health, Health Canada, Human Resources Development Canada, and the Canadian Institute for Health Information. These organizations have undertaken to keep this information confidential and use it only for statistical purposes. Do you agree to share the information you have provided?

___	Yes

___	No

H06-TEL	Was this interview conducted on the telephone or in person?

___	On telephone

___	In person

___	Both (Specify reason)

H06-CTEXT	Was the respondent alone when you asked this health questionnaire?

___	Yes	(Go to H06-P2)

___	No

H06-CTEXT1	Do you think that the answers of the respondent were affected by someone else being there?

___	Yes (Specify)

___	No

H06-P2	Record language of interview

English	Persian (Farsi)

French	Polish

Arabic	Portuguese

Chinese	Punjabi

Cree	Spanish

German	Tagalog (Filipino)

Greek	Ukrainian

Hungarian	Vietnamese

Italian	Other (Specify_______________)

Korean

Notes: