2011 BRFSS Questionnaire - English version

2011

Behavioral Risk Factor Surveillance System Questionnaire

January 27, 2011

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Behavioral Risk Factor Surveillance System 2011 Draft Questionnaire

Table of Contents

Table of Contents ............................................................................................................ 2 Interviewer`s Script .......................................................................................................... 4 Core Sections.................................................................................................................. 6

Section 1: Health Status ........................................................................................................................... 6 Section 2: Healthy Days -- Health-Related Quality of Life ...................................................................... 6 Section 3: Health Care Access ................................................................................................................. 7 Section 4: Hypertension Awareness......................................................................................................... 8 Section 5: Cholesterol Awareness............................................................................................................ 8 Section 6: Chronic Health Conditions ....................................................................................................... 9 Section 7: Tobacco Use.......................................................................................................................... 12 Section 8: Demographics........................................................................................................................ 14 Section 9: Fruits and Vegetables............................................................................................................ 20 Section 10: Exercise (Physical Activity).................................................................................................. 24 Section 11: Disability .............................................................................................................................. 26 Section 12: Arthritis Burden .................................................................................................................... 26 Section 13: Seatbelt Use ........................................................................................................................ 28 Section 14: Immunization ....................................................................................................................... 28 Section 15: Alcohol Consumption........................................................................................................... 29 Section 16: HIV/AIDS ............................................................................................................................. 30 Closing/Transition Statement ...................................................................................................................... 30

Optional Modules .......................................................................................................... 32

Module 1: Pre-Diabetes .......................................................................................................................... 32 Module 2: Diabetes ................................................................................................................................. 32 Module 3: Healthy Days (Symptoms) ..................................................................................................... 35 Module 4: Sugar Sweetened Beverages and Menu Labeling ................................................................ 36 Module 5: Preconception Health/Family Planning.................................................................................. 36 Module 6: Visual Impairment and Access to Eye Care .......................................................................... 39 Module 7: Inadequate Sleep................................................................................................................... 42 Module 8: High Risk/Health Care Worker............................................................................................... 43 Module 9: Cardiovascular Health ........................................................................................................... 44 Module 10: Actions to Control High Blood Pressure .............................................................................. 45 Module 11: Heart Attack and Stroke....................................................................................................... 48 Module 12: Breast/Cervical Cancer Screening ...................................................................................... 50 Module 13: Prostate Cancer Screening.................................................................................................. 52 Module 14: Colorectal Cancer Screening ............................................................................................... 54 Module 15: Smoking Cessation .............................................................................................................. 55 Module 16: Secondhand Smoke ............................................................................................................ 57 Module 17: Adult Asthma History ........................................................................................................... 59 Module 18: Arthritis Management........................................................................................................... 62 Module 19: Tetanus Diphtheria (Adults) ................................................................................................. 63 Module 20: Adult Human Papilloma Virus (HPV) ................................................................................... 64 Module 21: Shingles ............................................................................................................................... 64 Module 22: Chronic Obstructive Pulmonary Disease (COPD) ............................................................... 65 Module 23: General Preparedness......................................................................................................... 66 Module 24: Veterans` Health .................................................................................................................. 68 Module 25: Reactions to Race ............................................................................................................... 70 Module 26: Anxiety and Depression ....................................................................................................... 72

2011 BRFSS/Final/January 27, 2011

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Module 27: Cognitive Impairment ........................................................................................................... 74 Module 28: Social Context...................................................................................................................... 77 Module 29: HIV/AIDS.............................................................................................................................. 79 Module 30: Emotional Support and Life Satisfaction.............................................................................. 79 Module 31: Adverse Childhood Experience ........................................................................................... 80 Module 32: Random Child Selection ...................................................................................................... 83 Module 33: Childhood Asthma Prevalence ............................................................................................ 85 Module 34: Child Immunization (Influenza) ............................................................................................ 85 Asthma Call-Back Permission Script ................................................................................................. 86 Activity List for Common Leisure Activities (To be used for Section 10: Physical Activity) ....... 87 List of Health Problems to Accompany Module 8, Question 3 ........................................................ 88 [DO NOT READ] .................................................................................................................................... 88

2011 BRFSS/Final/January 27, 2011

Interviewers Script

HELLO, I am calling for the (health department) . My name is

(name) . We are gathering

information about the health of (state) residents. This project is conducted by the health department

with assistance from the Centers for Disease Control and Prevention. Your telephone number has been

chosen randomly, and I would like to ask some questions about health and health practices.

Is this

(phone number) ? If "no," Thank you very much, but I seem to have dialed the wrong number. It`s possible that your number may be called at a later time. STOP

Is this a private residence in (state) ? If "no," Thank you very much, but we are only interviewing private residences in (state) . STOP

Is this a cellular telephone?

[Read only if necessary: "By cellular (or cell) telephone we mean a telephone that is mobile and usable outside of your neighborhood."

If "yes,"

Thank you very much, but we are only interviewing land line telephones and private residences. STOP

I need to randomly select one adult who lives in your household to be interviewed. How many members of your household, including yourself, are 18 years of age or older?

__ Number of adults

If "1," Are you the adult?

If "yes," Then you are the person I need to speak with. Enter 1 man or 1 woman below (Ask gender if necessary). Go to page 5.

If "no," Is the adult a man or a woman? Enter 1 man or 1 woman below. May I speak with [fill in (him/her) from previous question]? Go to "correct respondent" on the next page.

How many of these adults are men and how many are women? __ Number of men __ Number of women

The person in your household that I need to speak with is

.

2011 BRFSS/Final/January 27, 2011

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If "you," go to page 4

To the correct respondent:

HELLO, I am calling for the (health department) . My name is

(name) . We are gathering

information about the health of (state) residents. This project is conducted by the health department

with assistance from the Centers for Disease Control and Prevention. Your telephone number has been

chosen randomly, and I would like to ask some questions about health and health practices.

2011 BRFSS/Final/January 27, 2011

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