HEALTH10 I1 In general, would you say your health is (Circle one number):
1 Excellent
2 Very Good
3 Good
4 Fair
5 Poor
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1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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1 Not at all
2 Slightly
3 Moderately
4 Quite a bit
5 Extremely
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PAIN10 I6 How much bodily pain have you had during the past 4 weeks?
1 None
2 Mild
3 Moderate
4 Severe
5 Very severe
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I7 Have you been told by your doctor that you have any of the following:
1 Yes
2 No
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BPRESS10 High blood pressure
HEART10 Heart condition
DIABET10 Diabetes
MENTAL10 Prolonged anxiety, depression or other mental health problems
CANCER10 Cancer
LUNG10 Chronic lung disease (emphysema, asthma, chronic bronchitis)
BONE10 Fractures or broken bones
DIGEST10 Chronic digestive disease (ulcer, colitis, liver problems)
EPILEP10 Epilepsy or a seizure disorder
BACK10 Chronic back problems
DEVELP10 Developmental problems (speech, language, learning)
OTHDIS10 Any other major disease, disability or handicap
CHECKU10 I8 About how long has it been since you last visited a doctor for a routine check-up?
1 Within the past year
2 Within the past two years
3 Within the past five years
4 More than 5 years ago
5 I have never had a routine check-up
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0 No
1 Yes
-9 MissingBREAKF10 I10 In an average week, how many days do you eat breakfast?
SLEEP10 I13 How many hours of sleep do you usually get in a 24 hour period?
1 Less than five
2 Six
3 Seven
4 Eight
5 Nine
6 More than nine
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ALCLIF10 I14 On how many occasions have you alcoholic beverages to drink in your lifetime?
1 None (GO TO I17)
2 1-2 times
3 3-5 times
4 6-9 times
5 10-19 times
6 20-39 times
7 40 or more times
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ALCMON10 I15 How many times have you had alcoholic beverages to drink during the past 30 days?
1 None (GO TO 117)
2 1-2 times
3 3-5 times
4 6-9 times
5 10-19 times
6 20-39 times
7 40 or more times
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1 None
2 Once
3 Twice
4 Three to five times
5 Six to nine times
6 Ten or more times
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SMOKE10 I17 Have you ever smoked cigarettes (tobacco)?
0 No (GO TO I22)
1 Yes (GO TO I18)
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CIG10010 I18 Have you smoked at least 100 cigarettes in your lifetime?
0 No
1 Yes
-9 MissingCIGMON10 I19 How often have you smoke cigarettes during the past 30 days?
1 None at all (GO TO 120)
2 Less than 1 cigarette each day (GO TO 122)
3 1 to 5 cigarettes each day (GO TO 122)
4 About a half pack each day (GO TO 122)
5 About 1 pack each day (GO TO 122)
6 About one and a half packs each day (GO TO 122)
7 About 2 packs or more each day (GO TO 122)
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I20 On average, when you were smoking, about how many cigarettes a day did you smoke?
HINSUR10 I22 Do you have health insurance?
0 No (GO TO I23)
1 Yes (GO TO I22A)
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I22A Do you get this insurance through: (Circle all that apply):
0 Not checked
1 Checked
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INSEMP10 Your employer
INSSPS10 Spouse or partner’s employer
INSSCH10 Your school
INSPRT10 Your parents (you are covered by your parents' policy)
INSPUB10 A public program (Medicaid, MN Care, AFDC)
INSYOU10 Yourself (you purchased it)
INSOTH10 Other
OTHSOU10 please specify: ______________________________
LONGLI10 I23 What do you think are the chances that you will live a long and healthy life?
1 Very high
2 High
3 About fifty-fifty
4 Low
5 Very low
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