2007

Behavioral Risk Factor Surveillance System 
Questionnaire

Delaware

Table of Contents

Table of Contents	
Interviewer’s Script
Core Sections	
Section 1: Health Status	
Section 2: Healthy Days — Health-Related Quality of Life	
Section 3: Health Care Access	
Section 4: Exercise	
Section 5: Diabetes	
Section 6: Hypertension Awareness	
Section 7: Cholesterol Awareness	
Section 8: Cardiovascular Disease Prevalence	
Section 9: Asthma	
Section 10: Immunization	
Section 11: Tobacco Use	
Section 12: Demographics	
Section 13: Alcohol Consumption	
Section 14: Disability	
Section 15: Arthritis Burden	
Section 16: Fruits and Vegetables	
Section 17: Physical Activity	
Section 18: HIV/AIDS	
Section 19: Emotional Support and Life Satisfaction	
Optional Modules	
Module 3: Diabetes	
Module 7: Actions to Control High Blood Pressure	
Module 9: Women’s Health	
Module 10: Prostate Cancer Screening	
Module 19: General Preparedness	
 

Interviewer’s Script

HELLO, I am calling for the Delaware Division of Public Health, from the 
University of Delaware.  My name is    (first name). We are gathering 
information about the health of Delaware 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?	
	If "no,"
	Thank you very much, but we are only interviewing private residences.
  STOP

Is this a cellular telephone?  

Read only if necessary: “By cellular 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 _________.

	If "you," go to page 4

To the correct respondent:	

HELLO, I am calling for the Delaware Division of Public Health, from the
University of Delaware.  My name is   first name) .  We are gathering
information about the health of Delaware 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.

Core Sections

I will not ask for your name, address, or other personal information that can
identify you.  You do not have to answer any question you do not want to, and 
you can end the interview at any time.  Any information you give me will be 
confidential.  If you have any questions, I will provide a telephone number for 
you to call to get more information.  [Office of Health Education, Division of
Public Health, 302-744-1000]

Section 1: Health Status

       
1.1 	Would you say that in general your health is—	
										(73)
	Please read:

	1	Excellent
	2	Very good
	3	Good
	4	Fair

	Or

	5	Poor

	Do not read:

	7	Don’t know / Not sure
	9	Refused

Section 2: Healthy Days — Health-Related Quality of Life

2.1 	Now thinking about your physical health, which includes physical illness
 	and injury, for hw many days during the past 30 days was your physical
 	health not good?	
										(74–75)
	_  _	Number of days
	8  8	None
	7  7	Don’t know / Not sure
	9  9	Refused

2.2	Now thinking about your mental health, which includes stress, depression,
 	and problems with emotions, for how many days during the past 30 days was
 	your mental health not good?
										(76–77)
	_  _	Number of days
	8  8	None 			[If Q2.1 and Q2.2 = 88 (None), go to next section] 
	7  7	Don’t know / Not sure
	9  9	Refused	


2.3	During the past 30 days, for about how many days did poor physical or 
	mental health keep you from doing your usual activities, such as self-
	care, work, or recreation?
										(78-79)
	_  _	Number of days
	8  8	None
	7  7	Don’t know / Not sure
	9  9	Refused


Section 3: Health Care Access

3.1	Do you have any kind of health care coverage, including health insurance,
 	prepaid plans such as HMOs, or government plans such as Medicare?
										(80)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused


3.2	Do you have one person you think of as your personal doctor or health care
 	provider?
	
	If “No,” ask: “Is there more than one, or is there no person who you think
 	of as your personal doctor or health care provider?”
										(81)
	1	Yes, only one
	2	More than one
	3	No 
	7	Don’t know / Not sure
	9	Refused

3.3	Was there a time in the past 12 months when you needed to see a doctor but
 	could not because of cost?
										(82)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

3.4	About how long has it been since you last visited a doctor for a routine
 	checkup? A routine checkup is a general physical exam, not an exam for a
 	specific injury, illness, or condition.  	
										(83)
	1	Within past year (anytime less than 12 months ago)
	2	Within past 2 years (1 year but less than 2 years ago)
	3	Within past 5 years (2 years but less than 5 years ago)
	4	5 or more years ago
	7	Don’t know / Not sure
	8	Never
	9	Refused

Section 4: Exercise

4.1	During the past month, other than your regular job, did you participate in 
	any physical activities or exercises such as running, calisthenics, golf,
 	gardening, or walking for exercise?
										(84)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

Section 5: Diabetes

5.1	Have you ever been told by a doctor that you have diabetes?

	If “Yes” and respondent is female, ask: “Was this only when you were
	pregnant?” 
	
	If respondent says pre-diabetes or borderline diabetes, use response code
 	4.
										(85)

	1	Yes 
	2	Yes, but female told only during pregnancy
	3	No
	4	No, pre-diabetes or borderline diabetes
	7	Don’t know / Not sure
	9	Refused


Section 6: Hypertension Awareness

6.1	Have you EVER been told by a doctor, nurse, or other health professional
 	that you have high blood pressure?							
	
										(86)
If “Yes” and respondent is female, ask: “Was this only when you were pregnant?”
	1	Yes
	2	Yes, but female told only during pregnancy 	[Go to next section]
	3	No 							[Go to next section]
	4	Told borderline high or pre-hypertensive 	[Go to next section]
	7	Don’t know / Not sure 				[Go to next section]
	9	Refused 						[Go to next section]


6.2	Are you currently taking medicine for your high blood pressure?		
										(87)
		1	Yes
		2	No	
		7	Don’t know / Not sure
		9	Refused

Section 7: Cholesterol Awareness

7.1	Blood cholesterol is a fatty substance found in the blood.  Have you EVER
 	had your blood cholesterol checked?							
										(88)
       	1	Yes
       	2	No 				[Go to next section]
       	7	Don’t know / Not sure	[Go to next section]
       	9	Refused 			[Go to next section]
       

7.2	About how long has it been since you last had your blood cholesterol
 	checked?
										(89)
       	Read only if necessary:
       	1	Within the past year (anytime less than 12 months ago)
       	2	Within the past 2 years (1 year but less than 2 years ago)
       	3	Within the past 5 years (2 years but less than 5 years ago)
       	4	5 or more years ago
       	Do not read:
       	7	Don’t know / Not sure
       	9	Refused

7.3	Have you EVER been told by a doctor, nurse or other health professional
	that your blood cholesterol is high?
										(90)
		1	Yes									
		2	No
       	7	Don’t know / Not sure
       	9	Refused


Section 8: Cardiovascular Disease Prevalence

Now I would like to ask you some questions about cardiovascular disease.

Has a doctor, nurse, or other health professional EVER told you that you had any
of the following? For each, tell me “Yes”, “No”, or you’re “Not sure.”		
	
8.1	(Ever told) you had a heart attack, also called a myocardial infarction?
										(91)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

8.2		(Ever told) you had angina or coronary heart disease?			
										(92)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

8.3	(Ever told) you had a stroke?							
										(93)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

Section 9: Asthma

9.1	Have you ever been told by a doctor, nurse, or other health professional
	that you had asthma?
										(94)
	1	Yes
	2	No 				[Go to next section] 
	7	Don’t know / Not sure 	[Go to next section]
	9	Refused			[Go to next section]


9.2	Do you still have asthma?
										(95)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

Section 10: Immunization

10.1	A flu shot is an influenza vaccine injected into your arm. During the past
	12 months, have you had a flu shot?
										(96)
	1	Yes
	2	No			
	7	Don’t know / Not sure	
	9	Refused		

10.2	During the past 12 months, have you had a flu vaccine that was sprayed in
	your nose? The flu vaccine sprayed in the nose is also called FluMist™.
										(97)
		1	Yes
		2	No			
		7	Don’t know / Not sure	
		9	Refused		

10.3	A pneumonia shot or pneumococcal vaccine is usually given only once or
 	twice in a 	person’s lifetime and is different from the flu shot. Have you
 	ever had a pneumonia shot?
										(98)

	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

10.4	Have you EVER received the hepatitis B vaccine? The hepatitis B vaccine is
 	completed after the third shot is given.
										(99)
INTERVIEWER NOTE:  Response is “Yes” only if respondent has received the third 
shot.
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

The next question is about behaviors related to Hepatitis B.


10.5	Please tell me if ANY of these statements is true for YOU. Do NOT tell me
 	WHICH statement or statements are true for you, just if ANY of them are:

	You have hemophilia and have received clotting factor concentrate
	You have had sex with a man who has had sex with other men, even just one
 		time
	You have taken street drugs by needle, even just one time
	You traded sex for money or drugs, even just one time
	You have tested positive for HIV
	You have had sex (even just one time) with someone who would answer "yes"
 		to any of these statements
	You had more than two sex partners in the past year

	Are any of these statements true for you?
										(100)
	1	Yes, at least one statement is true
	2	No, none of these statements is true
	7	Don’t know / Not sure
	9	Refused


Section 11: Tobacco Use

11.1	Have you smoked at least 100 cigarettes in your entire life?
										(101)
	NOTE: 	5 packs = 100 cigarettes
	1	Yes
	2	No 				[Go to next section]
	7	Don’t know / Not sure 	[Go to next section]
	9	Refused 			[Go to next section]



11.2	Do you now smoke cigarettes every day, some days, or not at all?
										(102)
	1	Every day
	2	Some days
	3	Not at all 			[Go to next section]
	7	Don’t know/Not sure	[Go to next section]
	9	Refused 			[Go to next section] 


11.3	During the past 12 months, have you stopped smoking for one day or longer
	because you were trying to quit smoking?
										(103)

	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused


Section 12: Demographics


12.1	What is your age?
										(104-105)
	_  _		Code age in years
	0  7   	Don’t know / Not sure
	0  9  	Refused 


12.2	Are you Hispanic or Latino?
										(106)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused


12.3 	Which one or more of the following would you say is your race?  
										(107-112)
	(Check all that apply)	
	Please read:

	1	White  
	2	Black or African American 
	3	Asian
	4	Native Hawaiian or Other Pacific Islander
	5	American Indian or Alaska Native
		Or
	6          Other [specify]______________
	Do not read:
	8	No additional choices
 	7	Don’t know / Not sure
	9	Refused


CATI note: If more than one response to Q12.3; continue.  Otherwise, go to
Q12.5.

12.4	Which one of these groups would you say best represents your race?
											(113)
	1	White  
	2	Black or African American 
	3	Asian
	4	Native Hawaiian or Other Pacific Islander
	5	American Indian or Alaska Native
	6	Other [specify] __________________
	Do not read:
	7	Don’t know / Not sure
	9	Refused


The next question relates to military service.


12.5	Have you ever served on active duty in the United States Armed Forces,
	either in the regular military or in a National Guard or military reserve
	unit?
											(114)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

12.6	Are you…?
											(115)
	Please read:
	1	Married
	2	Divorced
	3	Widowed
	4	Separated
	5	Never married
	Or
	6	A member of an unmarried couple
	Do not read:
	9	Refused

12.7	How many children less than 18 years of age live in your household?
											(116-117)
		_  _	Number of children
		8  8	None
		9  9	Refused


12.8	What is the highest grade or year of school you completed?
											(118)
		Read only if necessary:
	1	Never attended school or only attended kindergarten
	2	Grades 1 through 8 (Elementary)
	3	Grades 9 through 11 (Some high school)
	4	Grade 12 or GED (High school graduate)
	5	College 1 year to 3 years (Some college or technical school)
	6	College 4 years or more (College graduate)
		Do not read:
	9	Refused

12.9	Are you currently…?
											(119)
		Please read:

	1	Employed for wages
	2	Self-employed
	3	Out of work for more than 1 year
	4	Out of work for less than 1 year
	5	A Homemaker
	6	A Student
	7	Retired
	Or
	8	Unable to work
	Do not read:
	9	Refused


12.10	Is your annual household income from all sources—
											(120-121)

	If respondent refuses at ANY income level, code ‘99’ (Refused)

		Read only if necessary:

	04	Less than $25,000	If “no,” ask 05; if “yes,” ask 03
			($20,000 to less than $25,000)

	03	Less than $20,000 	If “no,” code 04; if “yes,” ask 02
			($15,000 to less than $20,000)

	02	Less than $15,000 	If “no,” code 03; if “yes,” ask 01
			($10,000 to less than $15,000)

	01	Less than $10,000 	If “no,” code 02

	05	Less than $35,000 	If “no,” ask 06
			($25,000 to less than $35,000)

	06	Less than $50,000 	If “no,” ask 07
			($35,000 to less than $50,000)

	07	Less than $75,000 	If “no,” code 08
			($50,000 to less than $75,000)

	08	$75,000 or more

		Do not read:

	77	Don’t know / Not sure
	99	Refused

12.11	About how much do you weigh without shoes?
											(122-125)

	Note: If respondent answers in metrics, put “9” in column 122.
	Round fractions up
		 _  _  _  _ 	Weight
		(pounds/kilograms)
		7  7  7  7	Don’t know / Not sure
		9  9  9  9	Refused


12.12	About how tall are you without shoes?
											(126-129)
	Note: If respondent answers in metrics, put “9” in column 126.	
	Round fractions down
	_ _ / _  _ 	Height
	(f t / inches/meters/centimeters)
	7  7  7  7	Don’t know / Not sure
	9  9  9  9	Refused	


12.13	What county do you live in?
											(130-132)
	_  _  _	 FIPS county code
	7  7  7      Don’t know / Not sure
	9  9  9      Refused
	

12.14   What is your ZIP Code where you live?	   					 
											(133-137)  
   
		_ _ _ _ _ 	ZIP Code
	7 7 7 7 7 	Don’t know / Not sure
	9 9 9 9 9 	Refused	


12.15	Do you have more than one telephone number in your household?  Do not
 	include cell phones or numbers that are only used by a computer or fax
	machine.
											(138)
	1	Yes
	2	No 			[Go to Q12.17]
	7	Don’t know / Not sure 	[Go to Q12.17]
	9	Refused 			[Go to Q12.17]

12.16		How many of these telephone numbers are residential numbers?
											(139)
	_	Residential telephone numbers [6 = 6 or more]
	7	Don’t know / Not sure
	9	Refused	

12.17	During the past 12 months, has your household been without telephone
	service for 1 week or more? Do not include interruptions of telephone service 
	because of weather or natural disasters.
											(140)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

12.18		Indicate sex of respondent.  Ask only if necessary.
											(141)

	1	Male  	[Go to next section]
	2	Female	[If respondent is 45 years old or older, go to next
				section]


12.19		To your knowledge, are you now pregnant?
											(142)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

Section 13: Alcohol Consumption

13.1	During the past 30 days, have you had at least one drink of any alcoholic
	beverage such as beer, wine, a malt beverage or liquor?			
											(143)
	1	Yes
	2	No 			[Go to next section]
	7	Don’t know / Not sure	[Go to next section]
	9	Refused			[Go to next section]


13.2	During the past 30 days, how many days per week or per month did you have
	at least one drink of any alcoholic beverage?
											(144-146)

	1_ _ _   	Days per week
	2_ _ _   	Days in past 30 days
	8  8  8   	No drinks in past 30 days 	[Go to next section]
 	7  7  7	Don’t know / Not sure 
	9  9  9	Refused 			


13.3	One drink is equivalent to a 12-ounce beer, a 5-ounce glass of wine, or a
	drink with one shot of liquor. During the past 30 days, on the days when
 	you drank, about how many drinks did you drink on the average?
											(147-148)
	_  _	Number of drinks
	7  7	Don’t know / Not sure
	9  9	Refused

13.4	Considering all types of alcoholic beverages, how many times during the
 	past 30 days did you have X [CATI X = 5 for men, X = 4 for women] or more
 	drinks on an occasion?
											(149-150)
	_  _	Number of times
	8  8    	None
	7  7    	Don’t know / Not sure
	9  9    	Refused

13.5	During the past 30 days, what is the largest number of drinks you had on
	any occasion?
											(151-152)
	_  _	Number of drinks
	7  7	Don’t know / Not sure
	9  9	Refused

Section 14: Disability

The following questions are about health problems or impairments you may have.

14.1	Are you limited in any way in any activities because of physical, mental,
 	or emotional problems?
											(153)
	1 	Yes
	2	No
	7	Don’t know / Not Sure
 	9	Refused

14.2	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?
											(154)
	Include occasional use or use in certain circumstances.

	1 	Yes
	2	No
	7	Don’t know / Not Sure
	9	Refused

Section 15: Arthritis Burden

The next questions refer to the joints in your body.  Please do NOT include the 
back or neck.


15.1	During the past 30 days, have you had symptoms of pain, aching, or
 	stiffness in or around a joint?		
											(155)
		1	Yes
		2	No  			[Go to Q15.4]
		7	Don’t know / Not sure  	[Go to Q15.4]
		9	Refused  			[Go to Q15.4]

15.2	Did your joint symptoms first begin more than 3 months ago?	
											(156)
		1	Yes
		2	No  			[Go to Q15.4]
		7	Don’t know / Not sure  	[Go to Q15.4]
		9	Refused  			[Go to Q15.4]


15.3	Have you ever seen a doctor or other health professional for these joint
 	symptoms?
											(157)
		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused


15.4	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?		
											(158)
		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused

INTERVIEWER NOTE:  Arthritis diagnoses include:
*	rheumatism, polymyalgia rheumatica
*	osteoarthritis (not osteoporosis)
*	tendonitis, bursitis, bunion, tennis elbow 
*	carpal tunnel syndrome, tarsal tunnel syndrome
*	joint infection, Reiter’s syndrome
*	ankylosing spondylitis; spondylosis
*	rotator cuff syndrome
*	connective tissue disease, scleroderma, polymyositis, Raynaud’s syndrome
*	vasculitis (giant cell arteritis, Henoch-Schonlein purpura, Wegener’s
	granulomatosis, polyarteritis nodosa)


15.5	Are you now limited in any way in any of your usual activities because of
 	arthritis or joint symptoms? 
											(159) 
       1 	Yes 
       2 	No 
       7 	Don’t know / Not sure 
       9 	Refused
        
      
INTERVIEWER NOTE: If a respondent question arises about medication, then the
interviewer should reply: “Please answer the question based on how you are when
you are taking any of the medications or treatments you might use.”

Section 16: Fruits and Vegetables

These next questions are about the foods you usually eat or drink.  Please tell
me how often you eat or drink each one, for example, twice a week, three times
a month, and so forth. Remember, I am only interested in the foods you eat.
Include all foods you eat, both at home and away from home.

16.1  How often do you drink fruit juices such as orange, grapefruit, or tomato?
											(160-162)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused

16.2  Not counting juice, how often do you eat fruit?
											(163-165)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused

16.3     	How often do you eat green salad?
											(166-168)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused

16.4	How often do you eat potatoes not including French fries, fried potatoes,
 	or potato chips?
											(169-171)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused

16.5  How often do you eat carrots?
											(172-174)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused

16.6	Not counting carrots, potatoes, or salad, how many servings of vegetables
	do you usually eat? (Example: A serving of vegetables at both lunch and
	dinner would be two servings.)
											(175-177)
	1 _ _	Per day
	2 _ _	Per week
	3 _ _    	Per month
	4 _ _    	Per year
	5 5 5 	Never
	7 7 7 	Don’t know / Not sure
	9 9 9 	Refused


Section 17: Physical Activity

CATI note: If Core Q12.8 = 1 (employed for wages) or 2 (self-employed) then
continue. Otherwise, Go to Q17.2.

17.1	When you are at work, which of the following best describes what you do?
	Would you say—
											(178)
	If respondent has multiple jobs, include all jobs.

	Please read:

	1	Mostly sitting or standing
	2	Mostly walking
	3	Mostly heavy labor or physically demanding work
	Do not read:
	7	Don’t know / Not sure
	9	Refused

Please read:											
		
We are interested in two types of physical activity - vigorous and moderate.
Vigorous activities cause large increases in breathing or heart rate while 
moderate activities cause small increases in breathing or heart rate.

17.2	Now, thinking about the moderate activities you do [fill in “when you are
 	not working” if “employed” or self-employed”] in a usual week, do you do
 	moderate activities for at least 10 minutes at a time, such as brisk 
	walking, bicycling, vacuuming, gardening, or anything else that causes
 	some increase in breathing or heart rate?
											(179)
	1	Yes
	2	No 			[Go to Q17.5]
	7	Don’t know / Not sure	[Go to Q17.5]
	9	Refused 			[Go to Q17.5]


17.3	How many days per week do you do these moderate activities for at least 10
	minutes at a time?	
											(180-181)
	_ _	Days per week
	8 8   Do not do any moderate physical activity for at least 10 minutes
		at a time? 		[Go to Q17.5]
	7 7	Don’t know / Not sure 	[Go to Q17.5]
	9 9	Refused 			[Go to Q17.5] 


17.4	On days when you do moderate activities for at least 10 minutes at a time,
	how much total time per day do you spend doing these activities?
											(182-184)
	_:_ _ 	Hours and minutes per day
	7 7 7     	Don’t know / Not sure
	9 9 9	Refused  


17.5  Now, thinking about the vigorous activities you do [fill in “when you are
	not working” if “employed” or “self-employed”] in a usual week, do you do
 	vigorous activities for at least 10 minutes at a time, such as running,
 	aerobics, heavy yard work, or anything else that causes large increases in
 	breathing or heart rate?	
											(185)
	1	Yes
	2	No 			[Go to next section]
	7	Don’t know / Not sure 	[Go to next section]
	9	Refused 			[Go to next section]


17.6	How many days per week do you do these vigorous activities for at least 10 
	minutes at a time?
											(186-187)
	_ _	Days per week
	8 8	Do not do any vigorous physical activity for at least 10 minutes
		at a time 			[Go to next section]
	7 7	Don’t know / Not sure	[Go to next section]
	9 9	Refused 			[Go to next section]

17.7	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?
											(188-190)
	_:_ _	Hours and minutes per day
	7 7 7	Don’t know / Not sure
     	9 9 9	Refused 


Section 18: HIV/AIDS

CATI note: If respondent is 65 years old or older, go to next section.
		
The next few questions are about the national health problem of HIV, the virus
that causes AIDS.  Please remember that your answers are strictly confidential
and that you don’t have to answer every question if you do not want to. 
Although we will ask you about testing, we will not ask you about the results of
any test you may have had.

18.1	Have you ever been tested for HIV?  Do not count tests you may have had as
 	part of a blood donation. Include testing fluid from your mouth.
											(191)
	1	Yes
	2	No 			[Go to next section]
	7	Don’t know / Not Sure 	[Go to next section]
	9	Refused	 		[Go to next section]

18.2	Not including blood donations, in what month and year was your last HIV
 	test?
											(192-197)
	NOTE:  If response is before January 1985, code “Don’t know.”
	_ _ /_ _ _ _ 	Code month and year
	7 7/ 7 7 7 7     	Don’t know / Not sure	
	9 9/ 9 9 9 9    	Refused

18.3	Where did you have your last HIV test — at a private doctor or HMO office,
 	at a counseling and testing site, at a hospital, at a clinic, in a jail or
 	prison, at a drug treatment facility, at home, or somewhere else?
											(198-199)
	01	Private doctor or HMO office
	02	Counseling and testing site
	03	Hospital
	04	Clinic
	05	Jail or prison (or other correctional facility)
	06	Drug treatment facility
	07	At home
	08	Somewhere else
	77	Don’t know/Not sure
	99	Refused	

CATI note: Ask Q.18.4; if Q.18.2 = within last 12 months. Otherwise, go to next
section.

18.4	Was it a rapid test where you could get your results within a couple of 
hours?
											(200)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

Section 19: Emotional Support and Life Satisfaction 

The next two questions are about emotional support and your satisfaction with
life.

19.1	How often do you get the social and emotional support you need?

INTERVIEWER NOTE:  If asked, say “please include support from any source.”
											(201)
	Please read:

	1	Always
	2	Usually
	3	Sometimes
	4	Rarely
	5	Never
	Do not read:
	7	Don't know / Not sure
	9	Refused

19.2	In general, how satisfied are you with your life?
											(202)
	Please read:
	1	Very satisfied
	2	Satisfied
	3	Dissatisfied
	4	Very dissatisfied
	Do not read:
	7	Don't know / Not sure
	9	Refused


Transition to Modules and/or State-Added Questions

Please read:

Finally, I have just a few questions left about some other health topics.

Optional Modules

Module 3: Diabetes

To be asked following Core Q5.1; if response is "Yes" (code = 1)

1.	How old were you when you were told you have diabetes?
											(221)
	_  _ 	Code age in years  [97 = 97 and older]	
	9  8	Don’t know / Not sure	
	9  9	Refused	

2.	Are you now taking insulin?
											(222)
	1	Yes
	2	No
	9	Refused

3.	Are you now taking diabetes pills?
											(223)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused

4.	About how often do you check your blood for glucose or sugar?  Include
 	times when checked by a family member or friend, but do NOT include times
 	when checked by a health professional.
											(224-226)

	1  _  _ 		Times per day
	2  _  _ 		Times per week
	3  _  _ 		Times per month
 	4  _  _ 		Times per year
 	8  8  8		Never
	7  7  7		Don’t know / Not sure
	9  9  9		Refused


5.	About how often do you check your feet for any sores or irritations?
  	Include times when checked by a family member or friend, but do NOT
 	include times when checked by a health professional.	
											(227-229)
		
	1  _  _          	Times per day
	2  _  _          	Times per week
	3  _  _  		Times per month
 	4  _  _  		Times per year
	5  5  5 		No feet
 	8  8  8 		Never
	7  7  7 		Don’t know / Not sure
	9  9  9 		Refused


6.	Have you ever had any sores or irritations on your feet that took more
	than four weeks to heal?
											(230) 
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused
	
7.	About how many times in the past 12 months have you seen a doctor, nurse,
 	or other health professional for your diabetes?
											(231-232)
	_  _ 	Number of times [76 = 76 or more]
	8  8 	None
	7  7	Don’t know / Not sure
	9  9 	Refused

8.	A test for "A one C" measures the average level of blood sugar over the
	past three months.  About how many times in the past 12 months has a 
	doctor, nurse, or other health professional checked you for "A one C"?
											(233-234)
	_  _ 	Number of times [76 = 76 or more]
	8  8 	None
	9  8	Never heard of “A one C” test
	7  7	Don’t know / Not sure
	9  9 	Refused

CATI Note:  If Q5 = 555 (No feet), go to Q10.

9.	About how many times in the past 12 months has a health professional
 	checked your feet for any sores or irritations?
											(235-236)

	_  _ 	Number of times [76 = 76 or more]
	8  8 	None
	7  7	Don’t know / Not sure
	9  9 	Refused


10.	When was the last time you had an eye exam in which the pupils were
 	dilated?  This would have made you temporarily sensitive to bright light.
											(237) 
	Read only if necessary:
	1	Within the past month (anytime less than 1 month ago)
	2 	Within the past year (1 month but less than 12 months ago)
	3 	Within the past 2 years (1 year but less than 2 years ago)
	4 	2 or more years ago
	Do not read: 
	7 	Don’t know / Not sure
	8	Never
	9 	Refused

11.	Has a doctor ever told you that diabetes has affected your eyes or that
 	you had retinopathy?
											(238)
	1 	Yes
	2 	No
	7 	Don’t know / Not sure
	9 	Refused

12.	Have you ever taken a course or class in how to manage your diabetes
	yourself?		
											(239)
	1 	Yes
	2 	No
	7 	Don't know / Not sure
	9	Refused

Module 7: Actions to Control High Blood Pressure

CATI note: If Core Q6.1 = 1 (Yes); continue. Otherwise, go to next module.

Are you now doing any of the following to help lower or control your high blood
pressure?

1.	(Are you) changing your eating habits (to help lower or control your high
	blood pressure)?
											(265)
	1	Yes
	2	No
	7	Don’t know / Not sure
	9	Refused  

2.	(Are you) cutting down on salt (to help lower or control your high blood
 	pressure)?
											(266)
	1	Yes
	2	No  
	3	Do not use salt
	7	Don’t know / Not sure
	9	Refused  


3.	(Are you) reducing alcohol use (to help lower or control your high blood
	pressure)?
											(267)
	1	Yes
	2	No  
	3	Do not drink
	7	Don’t know / Not sure  		
	9	Refused  

4.	(Are you) exercising (to help lower or control your high blood pressure)?
											(268)
	1	Yes
	2	No  
	7	Don’t know / Not sure  		
	9	Refused  

Has a doctor or other health professional ever advised you to do any of the 
following to help lower or control your high blood pressure?		

5.	(Ever advised you to) change your eating habits (to help lower or control
 	your high blood pressure)? 
											(269)
	1	Yes
	2	No  
	7	Don’t know / Not sure  		
	9	Refused  


6.	(Ever advised you to) cut down on salt (to help lower or control your high
 	blood pressure)?
											(270)
	1	Yes
	2	No  
	3	Do not use salt
	7	Don’t know / Not sure  		
	9	Refused  


7.	(Ever advised you to) reduce alcohol use (to help lower or control your
 	high blood pressure)?
											(271)
	1	Yes
	2	No  
	3	Do not drink
	7	Don’t know / Not sure 
	9	Refused  

8.	(Ever advised you to) exercise (to help lower or control your high blood
 	pressure)?
											(272)
	1	Yes
	2	No  
	7	Don’t know / Not sure  		
	9	Refused  


9.	(Ever advised you to) take medication (to help lower or control your high
 	blood pressure)?
											(273)
	1	Yes
	2	No  
	7	Don’t know / Not sure 
	9	Refused  

10.	Were you told on two or more different visits to a doctor or other health
 	professional that you had high blood pressure?
											(274)

	If “Yes” and respondent is female, ask: “Was this only when you were
 	pregnant?”	
	1	Yes
	2	Yes, but female told only during pregnancy  
	3	No  
	4	Told borderline or pre-hypertensive  
	7	Don’t know / Not sure  
	9	Refused  

Module 9: Women’s Health

CATI note: If respondent is male, go to the next module.

The next questions are about breast and cervical cancer.

1.	A mammogram is an x-ray of each breast to look for breast cancer.  Have
	you ever had a mammogram?
											(288)
	1	Yes
	2	No  			[Go to Q3]
	7	Don’t know / Not sure 	[Go to Q3]
	9	Refused 			[Go to Q3]

 2.	How long has it been since you had your last mammogram?
											(289)
	Read only if necessary:
	1	Within the past year (anytime less than 12 months ago)
	2	Within the past 2 years (1 year but less than 2 years ago)
	3	Within the past 3 years (2 years but less than 3 years ago)
	4	Within the past 5 years (3 years but less than 5 years ago)
	5	5 or more years ago
	Do not read:
	7	Don’t know / Not sure
	9	Refused


 3.	A clinical breast exam is when a doctor, nurse, or other health
 	professional feels the breasts for lumps.  Have you ever had a clinical
 	breast exam?
											(290)
	1 	Yes
	2	No 			[Go to Q5]
	7	Don’t know / Not sure 	[Go to Q5]
	9	Refused 			[Go to Q5]


 4.	How long has it been since your last breast exam?
											(291)
	Read only if necessary:
	1	Within the past year (anytime less than 12 months ago)
	2	Within the past 2 years (1 year but less than 2 years ago)
	3	Within the past 3 years (2 years but less than 3 years ago)
	4	Within the past 5 years (3 years but less than 5 years ago)
	5	5 or more years ago
	Do not read:
	7	Don’t know / Not sure
	9	Refused


 5.	A Pap test is a test for cancer of the cervix.  Have you ever had a Pap
 	test?
											(292)
	1 	Yes
	2	No  			[Go to Q7]		
	7	Don’t know / Not Sure 	[Go to Q7]	
	9	Refused 			[Go to Q7]	

6.	How long has it been since you had your last Pap test?
											(293)
	Read only if necessary:
	1	Within the past year (anytime less than 12 months ago)
	2	Within the past 2 years (1 year but less than 2 years ago)
	3	Within the past 3 years (2 years but less than 3 years ago)
	4	Within the past 5 years (3 years but less than 5 years ago)
	5	5 or more years ago
	Do not read:
	7	Don’t know / Not sure
	9	Refused

CATI note: If response to Core Q12.18 = 1 (is pregnant); then go to next module.

7.	Have you had a hysterectomy?
											(294)

	Read only if necessary:  A hysterectomy is an operation to remove the
 	uterus (womb).

	1	Yes
	2	No
	7    	Don’t know / Not sure
	9    	Refused


Module 10: Prostate Cancer Screening

CATI note: If respondent is <39 years of age, or is female, go to next module.

Now, I will ask you some questions about prostate cancer screening.

1.	A Prostate-Specific Antigen test, also called a PSA test, is a blood test
 	used to check men for prostate cancer.  Have you ever had a PSA test?
											(295)

	1	Yes	
	2	No  			[Go to Q3]
	7	Don’t Know / Not Sure  	[Go to Q3]
	9	Refused  			[Go to Q3]


 2.	How long has it been since you had your last PSA test?
											(296) 
	Read only if necessary:
	1	Within the past year (anytime less than 12 months ago)
	2	Within the past 2 years (1 year but less than 2 years)
	3	Within the past 3 years (2 years but less than 3 years)
	4	Within the past 5 years (3 years but less than 5 years)
	5	5 or more years ago
	Do not read:
	7	Don’t know
	9	Refused

3.	A digital rectal exam is an exam in which a doctor, nurse, or other health
 	professional places a gloved finger into the rectum to feel the size,
 	shape, and hardness of the prostate gland. Have you ever had a digital
 	rectal exam?
											(297)
	1 	Yes
	2	No  			[Go to Q5]
	7	Don’t know / Not sure 	[Go to Q5]
	9	Refused  			[Go to Q5]

4.	How long has it been since your last digital rectal exam?
											(298)
		Read only if necessary:
	1	Within the past year (anytime less than 12 months ago)
	2	Within the past 2 years (1 year but less than 2 years)
	3	Within the past 3 years (2 years but less than 3 years)
	4	Within the past 5 years (3 years but less than 5 years)
	5	5 or more years ago
	Do not read:
	7	Don’t know / Not sure
	9	Refused

5.	Have you ever been told by a doctor, nurse, or other health professional
 	that you had prostate cancer? 
											(299)
	1	 Yes
	2	 No
	7	 Don’t know / Not sure
	9	 Refused

Module 19: General Preparedness 

The next series of questions asks about large-scale disasters or emergencies. By
large-scale disaster or emergency we mean any event that leaves you isolated in
your home or displaces you from your home for at least 3 days. This might
include natural disasters such as hurricanes, tornados, floods, and ice storms,
or man-made disasters such as explosions, terrorist events, or blackouts.

Some people may feel uncomfortable with these questions. Please keep in mind
that you can ask me to skip any question that you do not want to answer.

1.	How well prepared do you feel your household is to handle a large-scale 
	disaster or emergency?  Would you say . . .
											(363)
		Please read:
		1	Well prepared
		2	Somewhat prepared
		3	Not prepared at all
		Do not read:
		7	Don’t know / Not sure
		9	Refused

2.	Does your household have a disaster evacuation plan, a written plan for
 	how you will leave your home, in case of a large-scale disaster or
	emergency that requires evacuation?
											(364)
		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused

3.	Does your household have a 3-day supply of water for everyone who lives
 	there? A 3-day supply of water is 1 gallon of water per person per day.
											(365)
		1	Yes
		2	No
		3	Don’t know / Not sure
		4	Refused

4.	Does your household have a 3-day supply of non-perishable food for
 	everyone who lives there?  By non-perishable we mean food that does not
	require refrigeration or cooking.
											(366)

		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused

5.	Does your household have a 3-day supply of prescription medication for
 	each person who takes prescribed medicines?
											(367)
		1	Yes
		2	No
		3	No one in household requires prescribed medicine
		7	Don’t know / Not sure
		9	Refused

6.	Does your household have a working battery operated radio and working
 	batteries for your use if the electricity is out?
											(368)

		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused

7.	Does your household have a working flashlight and working batteries for
 	your use if the electricity is out?
											(369)
		1	Yes
		2	No
		7	Don’t know / Not sure
		9	Refused

8.	If public authorities announced a mandatory evacuation from your community
 	due to a large-scale disaster or emergency, would you evacuate?
											(370)

		1	Yes		[Go to Q10]
		2	No
		7	Don’t know / Not sure
		9	Refused

9.	What would be the main reason you might not evacuate if asked to do so?
											(371-372)
		Read only if necessary:
		01	Lack of transportation
		02	Lack of trust in public officials
		03	Concern about leaving property behind
		04	Concern about personal safety
		05	Concern about family safety
		06	Concern about leaving pets
		07	Other
		Do not read:
		77	Don’t know / Not sure
		99	Refused


10.	In a large-scale disaster or emergency, what would be your main method of
	communicating with relatives and friends?
											(373)
		Read only if necessary:
		1	Regular home telephones
		2	Cell phones
		3	Email
		4	Pager
		5	2-way radios
		6	Other
		Do not read:
		7	Don’t know / Not sure
		9	Refused


11.	What would be your main method of getting information from authorities in
 	a large-scale disaster or emergency?
											(374)
		Read only if necessary:
		1	Television
		2	Radio
		3	Internet
		4	Print media
		5	Neighbors
		6	Other
		Do not read:
		7	Don’t know / Not sure
		9	Refused

Closing statement

Please read:

That is my last question.  Everyone’s answers will be combined to give us
information about the health practices of people in this state.  Thank you very
much for your time and cooperation.

DATA LAYOUT - STATE-ADDED QUESTIONS
FOR 2007 BRFSS QUESTIONNAIRE -   Delaware


											401
A blood stool test is a test that may use a special kit at
home to determine whether the stool contains blood.  Have
you EVER had this test using a home kit?
1 Yes
2 No [Skip to 404]
7 DK/NS [Skip to 404]
9 Ref   [Skip to 404]

											402
How long has it been since you had your last blood stool test using a home kit?
1 w/in 1 yr
2 1-2 yrs
3 3-5 yrs
4 5+ yrs
7 DK/NS
9 Ref

											403
Why did you do your most recent at home blood test?
Was it. . .
1 part of routine examination
2 because of health problem
3 follow-up of earlier test
4 another reason
DO NOT READ
7 DK/NS
9 Ref

											404
Which of the following statements best describes your thoughts about doing an
at-home stool blood test in the future?
1 don’t want to do a stool blood test
2 I’m not sure if I want to do a stool blood test
3 I will if my doc says its necessary
4 I want to do a blood stool test
DO NOT READ
7 DK/NS
9 Ref

											405
Sigmoidoscopy and colonoscopy are exams in which a tube is inserted in the
rectum to view the colon for signs of cancer or other health problems. Have you
EVER had either of these exams?
1 	Yes
2 	No	[Skip to 409]
7 	DK/NS	[Skip to 409] 
9 	Ref	[Skip to 409]

											406
How long has it been since you had your last sigmoidoscopy or colonoscopy?
1 	Past yr
2 	1-2 yrs
3 	3-5 yrs
4 	5-10 yrs
5 	10+ yrs
7 	DK/NS
9 	Ref

											407
Why did you get your most recent sigmoidoscopy or colonoscopy?
1 	part of routine examination
2 	because of health problem
3 	follow-up of earlier test
4 	another reason
DO NOT READ
7 	DK
9 	Ref

											408
For a sigmoidoscopy, a flexible tube is inserted into the rectum to look for
problems.  A colonoscopy is similar, but uses a longer tube, and you’re usually
given medication through a needle in your arm to make you sleepy and told to
have someone else drive you home after the test.  Was your MOST RECENT
examination called a “sigmoidoscopy” or a “colonoscopy”?
1 	sigmoidoscopy
2 	colonoscopy
3 	something else
7 	DK/NS
9 	Refused

											409
Which of the following statements best describes your thoughts about having a
colonoscopy in the future?

1 	I don’t want to have a colonoscopy
2 	I’m not sure if I want to have a colonoscopy
3 	I will have a colonoscopy if my doctor says I need it
4 	I want a colonoscopy to see if I have any problems
DO NOT READ
7 	DK/NS
9	Refused


 											410
During the past year, has your doctor or health care professional talked to you
about the importance of being tested for colorectal cancer?
1 	Yes
2 	No
7 	DK/NS
9 	Refused

											411-412

[ASK CIGARETTE SMOKERS ONLY – FROM CORE]
Previously, you said you smoke cigarettes.  

On average, about how many cigarettes a day do you smoke (on days you smoke)?
01 	___ ___ (76=76 or more)
77 	KN/NS
00 	Refused

											413-414

[ASK FORMER SMOKERS ONLY – FROM CORE]
You told us you used to smoke cigarettes.  About how long has it been since you
last smoked cigarettes?
[DO NOT READ]
01 	Within past month
02	Within past three months
03 	Within past six months
04 	Within past year
05 	Within past five years
06 	Within past 10 years
07 	10 or more years ago
77 	DK/NS
99 	Refused

											415
Previously, we asked questions about cigarette smoking.  Now we have a few 
questions about other tobacco products:

Do you currently use cigars, pipes, chewing tobacco, snuff, kreteks, bidis, or
any other tobacco products?

Note:  Bidis are small, brown, hand-rolled cigarettes from India or southeast
Asia. Kreteks are clove cigarettes from Indonesia that contain both clove
extract and tobacco.
1 	Yes
2 	No 	[skip to 416]
7 	DK/NS  	[skip to 416]
9 	Refused  	[skip to 416]


											416
Do you now use chewing tobacco or snuff every day, some days or not at all?
1 	Every day
2 	Some days
3 	Not at all
7 	DK/NS
9 	Refused

											417
Do you now smoke cigars every day, some days, or not at all?
1 Every day
2 Some days
3 Not at all
7 DK/NS
9 Refused

											418
Which statement best describes rules about smoking inside your home?
1 	Smoking is not allowed anywhere inside my home
2 	Smoking is allowed some places or at some times
3 	Smoking is allowed anywhere inside my home
OR
4 	There are no rules about smoking inside my home
DO NOT READ
7 	DK/NS
9 	Refused

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