1 Appendix B2 Short Survey

Appendix B2-Short Version of Instrument
National Institutes of Health
U.S. Department of Health and Human Services
OMB # 0925-0538
Expiration Date: March 30, 2009

Health
Information

National Trends Survey

OM-2-E

A5. Based on the results of your most recent search
for information about health or medical topics,
how much do you agree or disagree with each of
the following statements?

A: Looking For Health Information
A1. Have you ever looked for information about
health or medical topics from any source?
Yes
No

GO TO A6 in the next column
a. It took a lot of effort to get the
information you needed .............

A2. The most recent time you looked for information
about health or medical topics, where did you go
first?

X

Mark

b. You felt frustrated during your
search for the information ..........

only one.

c.

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner
Other-Specify

d. The information you found was
hard to understand ....................

A6. Overall, how confident are you that you could
get advice or information about health or
medical topics if you needed it?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

A7. In general, how much would you trust
information about health or medical topics from
each of the following?

A3. Did you look or go anywhere else that time?
Yes
No

A4

You were concerned about the
quality of the information ...........

The most recent time you looked for information
about health or medical topics, who was it for?

a. A doctor ......................................
b. Family or friends .........................

Myself
Someone else
Both myself and someone else

c.

Newspapers or magazines .........

d. Radio ..........................................
e. Internet........................................
f.

Television....................................

g. Government health agencies ......
h. Charitable organizations .............
i.

1

Religious organizations and
leaders ........................................

A8. Imagine that you had a strong need to get
information about health or medical topics.
Where would you go first?

X

Mark

A11. Genetic tests that analyze your DNA, diet and
lifestyle for potential health risks are currently
being marketed by companies directly to
consumers. Have you heard or read about
these genetic tests?

only one.

Books
Brochures, pamphlets, etc.
Cancer organization
Family
Friend/Co-worker
Doctor or health care provider
Internet
Library
Magazines
Newspapers
Telephone information number
Complementary, alternative, or unconventional
practitioner
Other-Specify

Yes
No

B: Using the Internet to Find Information
B1. Do you ever go on-line to access the Internet or
World Wide Web, or to send and receive e-mail?
Yes
No ! GO TO C1 on the next page

B2. When you use the Internet, do you access it
through...
Yes No

a. A regular dial-up telephone line ...............

A9. Have you ever looked for information about
cancer from any source?

b. Broadband such as DSL, cable or FiOS ..
c.

Yes
No

d. A wireless network (Wi-Fi) ......................

A10. How much attention do you pay to information
about health or medical topics from each of the
following sources?

B3. Do you access the Internet any other way?
Yes- Specify!
No

B4. In the past 12 months, have you used the
Internet to look for health or medical information
for yourself?

a. In online newspapers ................
b. In print newspapers ...................
c.

A cellular network (i.e., telephone,
3G/4G) .....................................................

Yes
No

In special health or medical
magazines or newsletters ..........

d. On the Internet ..........................

B5. Is there a specific Internet site you like to go to
for health or medical information?

e. On the radio ...............................
f.

On local television news
programs ...................................

Yes
No

g. On national or cable television
news programs ..........................

GO TO C1 on the next page

B6. Specify which Internet site you especially like as
a source of health or medical information:

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C5. In the past 12 months, not counting times you
went to an emergency room, how many times
did you go to a doctor, nurse, or other health
professional to get care for yourself?

C: Your Health Care
C1. Not including psychiatrists and other mental
health professionals, is there a particular doctor,
nurse, or other health professional that you see
most often?

None
GO TO D1 on the next page
1 time
2 times
3 times
4 times
5-9 times
10 or more times

Yes
No

C2. Do you have any of the following health
insurance or health coverage plans:
Yes No

C6. The following questions are about your
communication with all doctors, nurses, or other
health professionals you saw during the past 12
months!

a. Insurance through a current or former
employer or union (of you or another
family member) .........................................
b. Insurance purchased directly from an
insurance company (by you or another
family member) .........................................
c.

How often did they do each
of the following:

Medicare ...................................................

d. Medicaid, Medical Assistance, or any
kind of government-assistance plan for
those with low incomes or a disability ......

a. Give you the chance to ask all
the health-related questions
you had? .....................................

e. TRICARE or other military health care .....

b. Give the attention you needed
to your feelings and emotions? ...

f.

VA (including those who have ever used
or enrolled for VA health care) .................

c.

g. Indian Health Service ...............................

Involve you in decisions about
your health care as much as
you wanted? ...............................

d. Make sure you understood the
things you needed to do to take
care of your health? ....................

C3. Do you have any other health care coverage
plan for yourself (please do not include dental or
vision plans)?

e. Explain things in a way you
could understand? ......................

Yes-Specify
No

f.

Spend enough time with you? ....

g. Help you deal with feelings of
uncertainty about your health or
health care? ................................

C4. 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.

C7. In the past 12 months, how often did you feel
you could rely on your doctors, nurses, or other
health care professionals to take care of your
health care needs?

Within past year (anytime less than 12 months
ago)
Within past 2 years (1 year but less than
2 years ago)
Within past 5 years (2 years but less than
5 years ago)
5 or more years ago
Don't know
Never

Always
Usually
Sometimes
Never

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C8. Overall, how would you rate the quality of health
care you received in the past 12 months?

D4. How often in the past 12 months would you say
you were worried or stressed about having
enough money to buy nutritious meals?

Excellent
Very good
Good
Fair
Poor

Always
Usually
Sometimes
Rarely
Never

D5. When available, how often do you use menu
information on calories in deciding what to
order?

D: Your Health, Nutrition
and Physical Activity

Always
Often
Sometimes
Rarely
Never

D1. In general, would you say your health is...
Excellent,
Very good,
Good,
Fair, or
Poor?

D6. About how many cups of fruit (including 100%
pure fruit juice) do you eat or drink each day?

D2. Over the past 2 weeks, how often have you
been bothered by any of the following problems?

None
" cup or less
" cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

a. Little interest or pleasure in
doing things ...............................
b. Feeling down, depressed or
hopeless ....................................
c.

1 cup of fruit could be:
- 1 small apple
- 1 large banana
- 1 large orange
- 8 large strawberries
- 1 medium pear
- 2 large plums
- 32 seedless grapes
- 1 cup (8 oz.) fruit juice
- " cup dried fruit
- 1 inch-thick wedge of

D7. About how many cups of vegetables (including
100% pure vegetable juice) do you eat or drink
each day?

Feeling nervous, anxious or on
edge ..........................................

d. Not being able to stop or control
worrying .....................................

None
" cup or less
" cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

D3. Overall, how confident are you about your ability
to take good care of your health?
Completely confident
Very confident
Somewhat confident
A little confident
Not confident at all

4

1 cup of vegetables could be:
- 3 broccoli spears
- 1 cup cooked leafy greens
- 2 cups lettuce or raw
greens
- 12 baby carrots
- 1 medium potato
- 1 large sweet potato
- 1 large ear of corn
- 1 large raw tomato
- 2 large celery sticks
- 1 cup of cooked beans

D8. How much sugar-sweetened soda or pop do you
usually drink each day? Do not include diet
sodas or diet pop.

D12. Over the past 30 days, in your leisure time, how
many hours per day, on average, did you sit and
watch TV or movies, surf the web, or play
computer games? Do not include “active
gaming” such as Wii.

None
12 ounces (1 can) or less
13 to 24 ounces (2 cans)
25 to 36 ounces (3 cans)
37 to 48 ounces (4 cans)
more than 48 ounces

Hours per day

D13. About how tall are you without shoes?
Feet

D9. In a typical week, how many days do you do any
physical activity or exercise of at least moderate
intensity, such as brisk walking, bicycling at a
regular pace, and swimming at a regular pace?

Inches

D14. About how much do you weigh, in pounds,
without shoes?

None
GO TO D11 below
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

Pounds

D15. How many times in the past 12 months have you
used a tanning bed or booth?
0 times
1 to 2 times
3 to 10 times
11 to 24 times
25 or more times

D10. On the days that you do any physical activity or
exercise of at least moderate intensity, how long
are you typically doing these activities?

D16. When you are outside for more than one hour on
a warm, sunny day, how often do you wear
sunscreen?

Write a number in one box below.
Minutes

and

Hours

Always
Often
Sometimes
Rarely
Never
Do not go out on sunny days

D11. In a typical week, outside of your job or work
around the house, how many days do you do
leisure-time physical activities specifically
designed to strengthen your muscles such as
lifting weights or circuit training (do not include
cardio exercise such as walking, biking, or
swimming)?

D17. Have you smoked at least 100 cigarettes in your
entire life?

None
1 day per week
2 days per week
3 days per week
4 days per week
5 days per week
6 days per week
7 days per week

Yes
No

GO TO D19 on the next page

D18. How often do you now smoke cigarettes?
Everyday
Some days
Not at all

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D19. A drink of alcohol is 1 can or bottle of beer,
1 glass of wine, 1 can or bottle of wine cooler,
1 cocktail, or 1 shot of liquor.

E3. How long ago did you have your most recent
Pap test to check for cervical cancer?
A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a Pap test

During the past 30 days, how many days per
week did you have at least one drink of any
alcoholic beverage?
0 days
1 day
2 days
3 days
4 days
5 days
6 days
7 days

GO TO D21 below

E4. A mammogram is an x-ray of each breast to look
for cancer.
Has a doctor ever told you that you could
choose whether or not to have a mammogram?
Yes
No

D20. During the past 30 days, on the days when you
drank, about how many drinks did you drink on
the average?

E5. When did you have your most recent
mammogram to check for breast cancer, if ever?

Drink(s)

A year ago or less
More than 1, up to 2 years ago
More than 2, up to 3 years ago
More than 3, up to 5 years ago
More than 5 years ago
I have never had a mammogram

D21. How much sleep do you usually get!
Hours

Minutes

a. On a workday or school day?
(i.e., weekday)? ............................
b. On a non-work or non-school
day (i.e., weekend)? .....................

E: Women and Cancer
Please continue on to the next page

E1. Are you male or female?
Male
GO TO F1 on the next page
Female

E2. Has a doctor ever told you that you could
choose whether or not to have the Pap test?
Yes
No

6

F5. Have you ever had a PSA test?

F: Screening for Cancer

Yes
No
Not sure

F1. A vaccine to prevent HPV infection is available
and is called the HPV shot, cervical cancer
vaccine, GARDASIL®, or Cervarix®.
Has a doctor or other health care professional
ever talked with you about the HPV shot or
vaccine?

F6. Has a doctor or other health care professional
ever told you that some doctors recommend the
PSA test and others do not?

Yes
No

Yes
No
Not sure

F2. There are a few different tests to check for colon
cancer. These tests include:

F7. Has a doctor or other health care professional
ever told you that no one is sure if using the
PSA test actually saves lives?

A colonoscopy – For this test, a tube is
inserted into your rectum and you are given
medication that may make you feel sleepy. After
the procedure, you need someone to drive you
home.

Yes
No
Not sure

A sigmoidoscopy – For this test, you are
awake when the tube is inserted into your
rectum. After the test you can drive yourself
home.

G: Beliefs About Cancer

A stool blood test – For this test, you collect a
stool sample at home, and then provide it to a
doctor or lab for testing.

Think about cancer in general when answering
the questions in this section.
G1. How likely are you to get cancer in your lifetime?

Has a doctor ever told you that you could
choose whether or not to have a test for colon
cancer?

Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

Yes
No

F3. Have you ever had a test to check for colon
cancer?

G2. Compared to other people your age, how likely
are you to get cancer in your lifetime?

Yes
No

Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

F4. (Females GO TO G1 in the next column. Males
continue with F4.) The following questions are
about discussions doctors or other health care
professionals may have with their patients about
the PSA test that is used to look for prostate
cancer.

G3. How worried are you about getting cancer?

Has a doctor ever told you that you could
choose whether or not to have the PSA test?

Not at all
Slightly
Somewhat
Moderately
Extremely

Yes
No

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G4. How much do you agree or disagree with each
of the following statements?

H3. At what age were you first told that you had
cancer?
Age

H4. Have any of your family members ever had
cancer?

a. It seems like everything causes
cancer ........................................
b. There’s not much you can do to
lower your chances of getting
cancer ........................................
c.

Yes
No
Not sure

There are so many different
recommendations about
preventing cancer, it's hard to
know which ones to follow .........

I: Medical Research and Medical Records
H: Your Cancer History

I1.

H1. Have you ever been diagnosed as having
cancer?
Yes
No

Yes
No

GO TO H4 in the next column

I2.
H2. What type of cancer did you have?

X

Mark

As far as you know, do any of your doctors or
other health care providers maintain your
medical information in a computerized system?

Please indicate how important each of the
following statements is to you.

all that apply.

Bladder cancer
Bone cancer
Breast cancer
Cervical cancer (cancer of the cervix)
Colon cancer
Endometrial cancer (cancer of the uterus)
Head and neck cancer
Hodgkin's lymphoma
Leukemia/Blood cancer
Liver cancer
Lung cancer
Melanoma
Non-Hodgkin lymphoma
Oral cancer
Ovarian cancer
Pancreatic cancer
Pharyngeal (throat) cancer
Prostate cancer
Rectal cancer
Renal (kidney) cancer
Skin cancer, non-melanoma
Stomach cancer
Other-Specify

a. Doctors and other health care
providers should be able to share
your medical information with each
other electronically .............................
b. You should be able to get to your
own medical information
electronically ......................................

I3.

Have you ever kept information from your health
care provider because you were concerned
about the privacy or security of your medical
record?
Yes
No

8

J5. What is the highest grade or level of schooling
you completed?

J: You and Your Household
J1. What is your age?

Less than 8 years
8 through 11 years
12 years or completed high school
Post high school training other than college
(vocational or technical)
Some college
College graduate
Postgraduate

Years old

J2. What is your current occupational status?

X

Mark

only one.

Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other-Specify

J6. Were you born in the United States?
Yes
No

GO TO J8 below

J7. In what year did you come to live in the
United States?

J3. Have you ever served on active duty in the U.S.
Armed Forces, military Reserves or National
Guard? Active duty does not include training in
the Reserves or National Guard, but DOES
include activation, for example, for the Persian
Gulf War.

Year

J8. How comfortable do you feel speaking English?
Completely comfortable
Very comfortable
Somewhat comfortable
A little comfortable
Not at all comfortable

Yes, now on active duty
Yes, on active duty in the last 12 months but
not now
Yes, on active duty in the past, but not in the
last 12 months
No, training for Reserves or
National Guard only
GO TO J4
No, never served in the military

J9. Are you Hispanic or Latino?
Yes
No

J3a. In the past 12 months, have you received some
or all of your health care from a VA hospital or
clinic?

J10. Which one or more of the following would you
say is your race?

Yes, all my health care
Yes, some of my health care
No, no VA health care received

X

Mark

one or more boxes.

American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
White

J4. What is your marital status?
Married
Living as married
Divorced
Widowed
Separated
Single, never been married

J11. Including yourself, how many people live in your
household?
Number of people

9

J12. Including yourself, please mark the gender, and
write in the age and month of birth for each adult
18 years of age or older living at this address.

J17. Thinking about members of your family living in
this household, what is your combined annual
income, meaning the total pre-tax income from
all sources earned in the past year?

Month Born
Gender

Adult 1

Male
Female

Adult 2

Male
Female

Adult 3

Male
Female

Adult 4

Male
Female

Adult 5

Male
Female

Age

$0 to $9,999
$10,000 to $14,999
$15,000 to $19,999
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $199,999
$200,000 or more

(01-12)

J18. Did you complete this survey all in one sitting, or
did you do it in more than one sitting?
I completed the survey all in one sitting.
I completed the survey in more than one sitting.

J13. How many children under the age of 18 live in
your household?

J19. Did anyone help you complete this survey?

Number of children under 18

Yes
No

J14. Do you currently rent or own your home?
J20. About how long did it take you to complete the
survey?

Own
Rent
Occupied without paying monetary rent

Write a number in one box below.
Minutes

J15. Does anyone in your family have a working cell
phone?

Hours

J21. At which of the following types of addresses
does your household currently receive
residential mail?

Yes
No

X

Mark

J16. Is there at least one telephone inside your home
that is currently working and is not a cell phone?

all that apply.

A street address with a house or building number
An address with a rural route number
A U.S. post office box (P.O. Box)
A commercial mail box establishment (such as
Mailboxes R Us, and Mailboxes Etc.)

Yes
No

10

Thank you!
Please return this questionnaire in the postage-paid envelope at your earliest convenience.

If you have lost the envelope, mail the completed questionnaire to:
HINTS Study, TC 1046F
Westat
1600 Research Boulevard
Rockville, MD 20850

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