Survey Questionnaires, Examination Components and Laboratory Components 2003-2004

The Questionnaires and Exam Components can be viewed using Adobe Acrobat reader.

 

Questionnaires

Questionnaires are administered to NHANES participants both at home and in the trailers. The questionnaires and a brief description of each section follows.

 

Screener Modules

• Screener Module 1 [PDF - 615.1 KB]. This is administered on the doorstep. This set of questions determines if anyone in the household is eligible to be in the sample.
• Screener Module 2 [PDF - 32 KB]. This establishes the relationship of everyone in the household to everyone else in the household.

 

Family Questionnaire

Household and family level information is collected here. The sections are labeled to reflect content.

• Demographic Background/Occupation [PDF - 89.4 KB]
• Food Security [PDF - 95.3 KB]
• Housing Characteristics [PDF - 49.2 KB]
• Income [PDF - 159 KB]
• Pesticide Use [PDF - 45.6 KB]
• Smoking [PDF - 30.4 KB]
• Tracking and Tracing [PDF - 47.8 KB]

 

Sample Person Questionnaire

Individual level information on participants is collected here. The sections are labeled to reflect content. Please note that the Medical Conditions section covers many subject areas.

• Acculturation [PDF - 53.1 KB]
• Audiometry [PDF - 44.7 KB]
• Balance [PDF - 53.7 KB]
• Blood Pressure [PDF - 72.9 KB]
• Cardiovascular Disease [PDF - 51.5 KB]
• Cardiovascular Fitness [PDF - 37.6 KB]
• Demographics Information [PDF - 113.3 KB]
• Dermatology [PDF - 60.1 KB]
• Diabetes [PDF - 51.8 KB]
• Dietary Supplements and Prescription Medication [PDF - 193.7 KB]
• Diet Behavior and Nutrition [PDF - 103.1 KB]
• Diet Behavior and Nutrition (Food Security Questions) [PDF - 16 KB]
• Dust Collection [PDF - 97.3 KB]
• Early Childhood [PDF - 52.9 KB]
• Health Insurance [PDF - 98.6 KB]
• Hospital Utilization and Access to Care [PDF - 56.4 KB]
• Immunization [PDF - 34.9 KB]
• Introduction and Verification [PDF - 51.6 KB]
• Kidney Conditions [PDF - 47.3 KB]
• Medical Conditions [PDF - 159.1 KB]
• Miscellaneous Pain [PDF - 51.1 KB]
• Occupation [PDF - 211.4 KB]
• Oral Health [PDF - 61 KB]
• Osteoporosis [PDF - 66.2 KB]
• Physical Activity and Physical Fitness [PDF - 112.4 KB]
• Physical Functioning [PDF - 84 KB]
• Respiratory Health and Disease [PDF - 33 KB]
• Respondent Selection [PDF - 89 KB]
• Smoking and Tobacco Use [PDF - 104.8 KB]
• Social Support [PDF - 38.5 KB]
• Vision [PDF - 75.3 KB]
• Weight History [PDF - 67.2 KB]

 

Post-Examination Questionnaires

• Food Frequency (formerly called Food Propensity):  Mailed to Respondent [PDF - 1.1 MB]
• Hepatitis Follow-up: Telephone Interview [PDF - 363 KB]
• Prostate Follow-up:  Telephone Interview [PDF - 72.6 KB]

 

Mental Health Questionnaires

This questionnaire was conducted in the Mobile Examination Center (MEC).

• Composite International Diagnostic Interview [PDF - 188 KB] consist of the following:
  Generalized Anxiety Disorder Module
  Major Depression Module
  Interview Panic Disorder Module
• Columbia University Diagnostic Schedule for Children (CDISC)
  • General Documentation [PDF - 148 KB]
  • DISC Interviewer Manual [PDF - 470 KB]
  • DISC Telephone Interviewer Manual [PDF - 128 KB]
  • Variable List [PDF - 3.3 MB]
  • Attention Deficit Hyperactivity Disorder (2000-2004) (Parent Questionnaire [PDF - 446 KB])
  • Conduct Disorder (2000-2004) (Parent Questionnaire [PDF - 572 KB])
  • Major Depression/Dysthymic Disorder (2000-2004) (Youth Questionnaire [PDF - 529 KB], Parent Questionnaire [PDF - 528 KB])
  • Eating Disorders (2000-2004) (Youth Questionnaire [PDF - 309 KB], Youth Questionnaire with Height and Weight Chart [PDF - 35 KB], Parent Questionnaire [PDF - 300 KB])
  • Elimination Disorders (2000-2004) (Parent Questionnaire [PDF - 309 KB])
  • Generalized Anxiety Disorder (1999-2004) (Youth Questionnaire [PDF - 256 KB])
  • Panic (1999-2004) (Youth Questionnaire [PDF - 250 KB])

 

MEC ACASI and CAPI Questionnaires

Audio computer assisted personal self interview (ACASI) and  computer assisted personal interview (CAPI) questionnaires are administered in the MEC.  During the visit to the examination center additional questions are administered that cover more sensitive areas such as reproductive health and illegal drug use. The sections are labeled to reflect content.

 

Audio Computer Assisted Personal Self Interview (ACASI) Questionnaire

• Alcohol (ages 12-19) [PDF - 56.5 KB]
• DISC Predictive Scale - Youth Conduct Disorder (ages 12-19) [PDF - 62.1 KB]
• Drugs (ages 12-59) [PDF - 56.9 KB]
• Food Security (ages 12-15) [PDF - 35.5 KB]
• Kidney Conditions (Prostate) [PDF - 95.7 KB]
• Sexual Behavior (ages 14-59) [PDF - 89.1 KB]
• Tobacco [PDF - 69.4 KB]

 

Computer Assisted Personal Interview (CAPI) Questionnaire

• Alcohol (ages 20+) [PDF - 40.1 KB]
• Current Health Status [PDF - 43.1 KB]
• Kidney [PDF - 44.1 KB]
• Physical Activity [PDF - 89.7 KB]
• Reproductive Health [PDF - 226.1 KB]
• Respondent Information [PDF - 36.4 KB]
• Tobacco (ages 20+) [PDF - 62.4 KB]

 

Examination and Laboratory

• Dietary Recall [PDF - 103 KB]
  • Measuring Guides for the Dietary Recall Interview
• Examination Components [PDF - 911 KB] consist of the following:
  • Audiometry
  • Balance and Vestibular Testing
  • Body Composition
  • Body Measurements
  • Cardiovascular Fitness
  • Dermatology
  • Lower Extremity Disease
  • Oral Health
  • Physical Activity Monitor
  • Physician's Exam
  • Vision
• Laboratory Components [PDF - 255 KB] consist of the following:
  • Blood & Urine
  • Venipuncture
  • Urine Collection
  • Bone Markers
  • Diabetes Profile
  • Infectious Disease Profile
  • Markers of Immunization Status
  • Miscellaneous Laboratory Assays
  • Kidney Disease Profile
  • Nutritional Biochemistries and Hematologies
  • Sexually Transmitted Disease Profile
  • Tobacco Use
  • Blood lipids
  • Environmental Health Profile [PDF - 154 KB]
• Special Studies [PDF - 27 KB]