Form 3 Cycle 3 Instrument - English

National Institutes of Health
U.S. Department of Health and Human Ser vices
OMB # 0925-0538
Expiration Date: October 31, 2014

Health
Information

National Trends Survey

C3

START HERE:
1.

Is there more than one person age 18 or older living in this household?
Yes
No

GO TO A1 on the next page

2.

Including yourself, how many people age 18 or older live in this household?

3.

The adult with the next birthday should complete this questionnaire. This
way, across all households, HINTS will include responses from adults of all
ages.

4.

Please write the first name, nickname or initials of the adult with the next
birthday. This is the person who should complete the questionnaire.

Si prefiere recibir la encuesta en español, por favor llame 1-888-738-6812

STATEMENT OF PRIVACY: Collection of this information is authorized by The Public Health Service Act, Sections 411 (42 USC 285 a) and 412 (42
USC 285a-1.a and 285a1.3). The purpose of this data collection is to evaluate whether the survey questions are easy to understand. The results of the
data collection will be used to improve the survey instrument. Rights of study participants are protected by The Privacy Act of 1974. Participation is
voluntary, and there are no penalties for not participating or withdrawing from the study at any time. Refusal to participate will not affect your benefits in
any way. The information collected in this study will be kept private under the Privacy Act and will only be seen by people authorized to work on this
project. The report summarizing the findings will not contain any names or identifying information. Identifying information will be destroyed when the
project ends.
NOTIFICATION TO RESPONDENT OF ESTIMATED BURDEN: Public reporting burden for this collection of information is estimated to average 30
minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a
collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other
aspect of this collection of information, including suggestions for reducing this burden to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC
7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0538). Do not return the completed form to this address.

2

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

Myself
Someone else
Both myself and someone else

GO TO A6 in the next column

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

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

A4. The most recent time you looked for
information about health or medical topics,
who was it for?

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. It took a lot of effort to get the
information you needed ............................
b. You felt frustrated during your
search for the information .........................
c.

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

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

3

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

a. A doctor ....................................................

A9. Have you ever looked for information about
cancer from any source?
Yes
No

A10. Do family members and friends ask you for
information or advice on health topics?
Yes
No

b. Family or friends................................
c.

Online newspapers ................................

d. Print newspapers ................................
e. In special health or medical
magazies or newsletters ..........................
f.

B: Using the Internet to Find Information

Radio ........................................................

g. Internet .....................................................
h. Local television................................
i.

National or cable television news
programs ..................................................

j.

Government health agencies ...................

k.

Charitable organizations ..........................

l.

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?
MarkX 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

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 B6 on the next page

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

a. A regular dial-up telephone line................
b. Broadband such as DSL, cable or FiOS ..
c.

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

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

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

4

B4. Sometimes people use the Internet to
connect with other people online through
social channels like Facebook or Twitter.
This is often called “social media.”

B6. In the past 12 months, have you used any of
the following to exchange medical
information with a health care professional?
Mark X all that apply.

In the last 12 months, have you used the
Internet for any of the following reasons?

E-mail
Text message
App on a smart phone or mobile device
Video conference (e.g., Skype, Facetime, etc.)
Social media (e.g., Facebook, Google+,
CaringBridge, etc.)
Fax
None

Yes No

a. Visited a social networking site, such as
Facebook or LinkedIn ..............................
b. Wrote in an online diary or blog (i.e.,
Web log) ...................................................
c.

Participated in an online forum or
support group for people with a similar
health or medical issue ............................

B7. Please indicate if you have each of the
following.

d. Shared health information on social
media sites, such as Facebook or
Twitter ......................................................

Mark X all that apply.

Tablet computer like an iPad, Samsung Galaxy,
Motorola Xoom, or Kindle Fire
Smartphone, such as an iPhone, Android,
Blackberry, or Windows phone
Cell phone
I do not have any of the above

e. Watched a health-related video on
YouTube...................................................

B5. Sometimes people use the Internet
specifically for health-related reasons.
In the last 12 months, have you used the
Internet for any of the following reasons?
Yes No

B8. How willing would you be to exchange the
following types of medical information with a
health care provider electronically through
your mobile phone or tablet?

a. Looked for health or medical information
for yourself ...............................................
b. Looked for health or medical information
for someone else .....................................
c.

Looked for information about quitting
smoking ....................................................

a. Appointment reminders ............................

d. Bought medicine or vitamins online .........

b. General health tips ................................

e. Looked for a health care provider ............

c.

f.

d. Lab/test results ................................

Downloaded health information to a
mobile device, such as a cell phone,
tablet computer or electronic book
device .......................................................

g. Kept track of personal health information
such as care received, test results, or
upcoming medical appointments .............
h. Used e-mail or the Internet to
communicate with a doctor or a doctor’s
office.........................................................

Medication reminders ...............................

e. Diagnostic information (i.e.,
medical illnesses or diseases) ..................
f.

Vital signs (e.g., heart rate, blood
pressure, glucose levels, etc.) ..................

g. Lifestyle behaviors (e.g., physical
activity, food intake, sleep
patterns, etc.) ................................
h. Symptoms (e.g., nausea, pain,
dizziness, etc.) ................................
i.

Digital images/video (e.g., photos
of skin lesions) ................................

5

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?

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?
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

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

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

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

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

C3. Do you have any other health care coverage
plan for yourself (please do not include
dental or vision plans)?
Yes-Specify
No

a. Give you the chance to ask all
the health-related questions you
had? ..........................................................
b. Give the attention you needed to
your feelings and emotions?.....................
c.

d. Make sure you understood the
things you needed to do to take
care of your health? ................................
e. Explain things in a way you
could understand? ................................
f.

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.
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

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

Spend enough time with you? ..................

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

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?
Always
Usually
Sometimes
Never
6

C8. Overall, how would you rate the quality of
health care you received in the past 12
months?
Excellent
Very good
Good
Fair
Poor

D: Medical Treatment

D3. In general, how often do you do each of the
following?

a. Take with you to your doctor
visits a list of questions or
concerns you want to cover ......................
b. Take a list of all of your
prescribed medicines to your
doctor visits ...............................................
c.

Medical decisions are choices you make with a
health care professional like which tests to have,
which medications to take or whether to have
surgery.

D1. When was the last time you made a medical
decision?
Within the past 12 months
More than 12 months ago
I have never made a
medical decision
GO TO D3 in the next
column

D2. Other than your main health care
professional, which of the following people
played an important role in your last medical
decision?
MarkX all that apply.
Spouse or partner
Parent
Child
Other family member
Friend or co-worker
Additional health care professional
No one else played an important role in my
decision
Other - Specify

Ask your doctor to explain a test,
treatment, or procedure to you in
detail .........................................................

d. Read information about a new
prescription, such as side effects
and precautions ................................
e. Do your own research on a
health or medical topic after
seeing your doctor ................................
f.

Take with you to your doctor
visit any kind of health
information you have found ......................

E: Medical Records
E1. As far as you know, do any of your doctors
or other health care providers maintain your
medical information in a computerized
system?
Yes
No

E2. Please indicate how important each of the
following statements is to you.

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 .............................................

7

E3. How much do you agree or disagree with
the following statement?
Scientists doing research should be able to
review my medical information if the
information cannot be linked to me
personally.
Strongly agree
Agree
Disagree
Strongly disagree

F: Genetics and Family History
F1. 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?
Yes
No

GO TO F3 in the next column

F2. From which of the following sources did you
read or hear anything about genetic tests?
Mark X all that apply.
Newspaper
Magazine
Radio
Health professional
Family member
Social media
Television
Internet
Other
Have not heard of such a test
Not sure

F3. Have you ever had any of the following
type(s) of genetic tests?
Mark X all that apply.
Paternity testing: to determine if a man is the
father of a child
Ancestry testing: to determine the background
or geographic/ethnic origin of an individual’s
ancestors
DNA fingerprinting: to distinguish between or
match individuals using hair, blood, or other
biological material
Cystic Fibrosis (CF) carrier testing: to
determine if a person is at risk of having a child
with cystic fibrosis
BRCA 1/2 testing: to determine if a person has
more than an average chance of developing
breast cancer or ovarian cancer
Lynch syndrome testing: to determine if a
person has more than an average chance of
developing colon cancer
None of the above
Not sure
Other-Specify
Have never had a genetic test

F4. If you had a genetic test, with whom did you
personally share the results?
MarkX all that apply.
Health professional
Family member
Friend
Other
Did not have this type of test
Did not communicate the results

F5. How important is it to know your family’s
health history for our own health?
Very important
Moderately important
Slightly important
Not at all important

8

G: Medical Research

H: Your Health, Nutrition and Physical
Activity

G1. How much do you agree or disagree with
the following statement?

H1. In general, would you say your health is...
Excellent,
Very good,
Good,
Fair, or
Poor?

Medical research provides information that
people need to make medical decisions.
Strongly agree
Somewhat agree
Somewhat disagree
Strongly disagree

G2. More and more, people are getting involved
in research in new ways beyond being a
research subject. They are partnering with
medical researchers to help decide what
research is done and how it is done. For
example, people can suggest important
topics to study or how to report results to the
public. This is sometimes called “patient
engagement” in research.
Yes

a. Have you ever heard about “patient
engagement” in medical research? .........
b. Have you ever engaged in medical
research in this way? ...............................
c.

Would you ever be interested in
engaging in research this way? ...............

H2. 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

H3. In the past 30 days, how often have you
felt…

Not
No sure

a. Happy? ................................
b. Angry? ......................................................
c.

Anxious? ................................

d. Hopeful? ................................
e. Sad? .........................................................

H4. How much do you agree or disagree with
each of the following statements?

a. When I feel threatened or
anxious I find myself thinking
about my strengths ................................
b. When I feel threatened or
anxious I find myself thinking
about my values................................
c.

I’m always optimistic about my
future ........................................................

9

H9. When available, how often do you use
menu information on calories in deciding what to
order?
Always
Often
Sometimes
Rarely
Never

H10. About how many cups of fruit (including
100% pure fruit juice) do you eat or drink
each day?
None
½ cup or less
½ cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

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
- ½ cup dried fruit
- 1 inch-thick wedge of
watermelon

The food label above can be found on the back of
a container of a pint of ice cream. We would like
to know how easy it is to use this information. Use H11. About how many cups of vegetables
the food label above to answer questions H7-H10.
(including 100% pure vegetable juice) do
you eat or drink each day?
H5. If you eat the entire container, how many
calories will you eat?
_____ calories

H6. If you are allowed to eat 60g of
carbohydrates as a snack, how much ice
cream could you have?
_____ cup(s) or _____ serving(s)

H7. Your doctor advises you to reduce the
amount of saturated fat in your diet. You
usually have 42g of saturated fat each day,
which includes 1 serving of ice cream. If you
stop eating ice cream, how many grams of
saturated fat would you be consuming each
day?
_____ grams

H8. If you usually eat 2,500 calories in a day,
what percentage of your daily value of
calories will you be eating if you eat one
serving?

None
½ cup or less
½ cup to 1 cup
1 to 2 cups
2 to 3 cups
3 to 4 cups
4 or more cups

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

H12. Not counting any diet soda or pop, about
how often do you drink regular soda or pop
in a typical week?
Every day
5-6 days a week
3-4 days a week
1-2 days a week
Less often than 1 day a week
I don’t drink any regular soda or pop

_____ percent
10

H13. In a typical week, how many days do you do H17. About how tall are you without shoes?
any physical activity or exercise of at least
Feet and
Inches
moderate intensity, such as brisk walking,
bicycling at a regular pace, and swimming at
a regular pace?
None
GO TO H17 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

H18. About how much do you weigh, in pounds,
without shoes?
Pounds

H19. How much sleep do you usually get…
Hours Minutes

H14. On the days that you do any physical activity
or exercise of at least moderate intensity,
how long do you typically do these
activities?

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

Write a number in one box below.
Minutes

Hours

H15. 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)?
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

H16. 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.

H20. 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

H21. When you are outside for more than one
hour on a warm, sunny day, how often do
you ...

a. Wear long pants?................................
b. Wear a hat that shades
your face, ears and neck? ........................
c.

Wear a shirt with sleeves
that cover your shoulders? .......................

d. Stay in the shade or under
an umbrella? ................................
e. Wear sunscreen?................................

Hours per day

11

I: Tobacco Products
I1.

I7.

Have you smoked at least 100 cigarettes in
your entire life?
Yes
No

I2.

GO TO I7 in the next column

Much less harmful,
Less harmful,
Just as harmful,
More harmful,
Much more harmful, or
I’ve never heard of electronic cigarettes

How often do you now smoke cigarettes?
Everyday
Some days
Not at all
GO TO I7 in the next column

I3.

On the average, when you smoked during
the past 30 days, about how many
cigarettes did you smoke a day?

I8.

1-10
11-19
20
21-39
40+

I4.

I5.

Are you seriously considering quitting
smoking in the next six months?
Yes
No

!

A hookah pipe (or shisha) is a large water
pipe. People smoke tobacco using hookah
pipes in groups at cafes or bars. Compared
to smoking cigarettes, would you say that
smoking tobacco using a hookah is…
Much less harmful,
Less harmful,
Just as harmful,
More harmful,
Much more harmful, or
I’ve never heard of Hookah

At any time in the past year, have you
stopped smoking for one day or longer
because you were trying to quit?
Yes
No

New types of cigarettes are now available
called electronic cigarettes (also known as
e-cigarettes or personal vaporizers). These
products deliver nicotine through a vapor.
Compared to smoking cigarettes, would you
say that electronic cigarettes are …

I9.

Do you believe that the United States Food
and Drug Administration (FDA) regulates
tobacco products in the U.S.?
Yes
No
Don’t know

GO TO I7 in the next column.

I6. About how long has it been since you
completely quit smoking cigarettes?
Less than 1 month ago
1 month to less than 3 months ago
3 months to less than 6 months ago
6 months to less than 1 year ago
1 year to less than 5 years ago
5 years to less than 15 years ago
15 years ago

I10. How much do you think quitting cigarette
smoking can help reduce the harmful effects
of smoking?
Not at all
A little
Some
A lot

12

I11. How much do you think each of the following J4.
help a current smoker reduce the harmful
effects of smoking if the person continues to
smoke?

A mammogram is an x-ray of each breast to
look for breast cancer. During the past 12
months, did a doctor, nurse, or other health
professional advise you to get a
mammogram?
Yes
No
Not sure

a. Exercising .................................................
b. Eating fruits and vegetables .....................
c.

J5.

Taking vitamins ................................

d. Sleeping at least 8 hours per
night .........................................................

I12. Which statement best describes the rules
about smoking inside your home?
Smoking is not allowed anywhere inside your
home
Smoking is allowed some places or at some
times
Smoking is allowed anywhere inside your home
There are no rules about smoking inside your
home

Has a doctor ever told you that you could
choose whether or not to have a
mammogram?
Yes
No

J6.

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

J: Women and Cancer
J1.

Male
GO TO SECTION K in the next column
Female

J2.

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

J3.

K: Screening for Cancer

Are you male or female?

K1. 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?
Yes
No

How long ago did you have your most recent
Pap test to check for cervical cancer?
K2. Have you ever heard of HPV? HPV stands
for Human Papillomavirus. It is not HIV,
A year ago or less
HSV, or herpes.
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

Yes
No
Not sure

13

K3. Do you think HPV can cause cervical
cancer?
Yes
No
Not sure

K8. 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.
Have you ever had a PSA test?

K4. Do you think that HPV is a sexually
transmitted disease (STD)?
Yes
No
Not sure

K5. Do you think that HPV will often go away on
its own without treatment?

Yes
No

K9. Has a doctor ever discussed with you
whether or not you should have the PSA
test?
Yes
No

Yes
No
Not sure

K6. There are a few different tests to check for
colon cancer. These tests include:
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.
A sigmoidoscopy – For this test, you are
awake when the tube is inserted into your
rectum. After the test you can drive yourself
home.
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.
Has a doctor ever told you that you could
choose whether or not to have a test for
colon cancer?
Yes
No

GO TO K12 below

K10. In that discussion, did the doctor ask you
whether or not you wanted to have the PSA
test?
Yes
No

K11. Did a doctor ever tell you that some experts
disagree about whether men should have
PSA tests?
Yes
No

K12. Has a doctor or other health care
professional ever told you that...
Yes No

a. The PSA test is not always accurate? ......
b. Some types of prostate cancer are slowgrowing and need no treatment?..............
c.

Treating any type of prostate cancer can
lead to serious side-effects, such as
problems with urination or having sex? ....

K7. Have you ever had one of these tests to
check for colon cancer?
Yes
No

!

Males, continue to K8.
Females, GO TO L1 on the next page.

14

L: Your Cancer History
L1.

Have you ever been diagnosed as having
cancer?
Yes
No

L2.

GO TO L4 below

What type of cancer did you have?
MarkX 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

M: Beliefs About Cancer
Think about cancer in general when
answering the questions in this section.
M1. How likely are you to get cancer in your
lifetime?
Very unlikely
Unlikely
Neither unlikely nor likely
Likely
Very likely

M2. Compared to other people your age, how
likely are you to get cancer in your lifetime?
Much less likely
Less likely
About the same
More likely
Much more likely

M3. Select one answer that best represents your
opinion about the statement: “I feel like I
could easily get cancer in my lifetime.”
I feel very strongly that this will NOT happen
I feel somewhat strongly that this will NOT
happen
I feel I am just as likely to get cancer as I am to
not get cancer
I feel somewhat strongly that this WILL happen
I feel very strongly that this WILL happen

M4. How worried are you about getting cancer?

L3.

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

L4.

Not at all
Slightly
Somewhat
Moderately
Extremely

Have any of your family members ever had
cancer?
Yes
No
Not sure

!

If you’ve been diagnosed with cancer at
any time in your life, please GO TO M4
in the next column
15

M5. How much do you agree or disagree with
each of the following statements?

N: You and Your Household
N1. What is your age?
Years old

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

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

d. In adults, cancer is more
common than heart disease.....................
e. When I think about cancer, I
automatically think about death

M6. How likely are you to get heart disease in
your lifetime?
I have heart disease
Very unlikely
Unlikely
Neither unlikely or likely
Likely
Very likely

N2. What is your current occupational status?
Mark X only one.
Employed
Unemployed
Homemaker
Student
Retired
Disabled
Other-Specify

N3. 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.
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
GO TO N5
No, training for Reserves or
below
National Guard only
No, never served in the military

N4. In the past 12 months, have you received
some or all of your health care from a VA
hospital or clinic?
Yes, all of my health care
Yes, some of my health care
No, no VA health care received

N5. What is your marital status?
Married
Living as married
Divorced
Widowed
Separated
Single, never been married

16

N6. What is the highest grade or level of
schooling you completed?
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

N7. Were you born in the United States?
Yes
No

GO TO N9 below

N8. In what year did you come to live in the
United States?
Year

N11. What is your race? One or more categories
may be selected.
Mark X all that apply.
White
Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

N12. Including yourself, how many people live in
your household?

N9. How well do you speak English?
Very well
Well
Not well
Not at all

N10. Are you of Hispanic, Latino/a, or Spanish
origin? One or more categories may be
selected.
MarkX all that apply.
No, not of Hispanic, Latino/a, or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino/a, or Spanish origin

Number of people

N13. Starting with yourself, please mark the sex,
and write in the age and month of birth for
each adult 18 years of age or older living at
this address.
Sex

SELF

Male
Female

Adult 2

Male
Female

Adult 3

Male
Female

Adult 4

Male
Female

Adult 5

Male
Female

Age

Month Born
(01-12)

17

N14. How many children under the age of 18 live
in your household?
Number of children under 18

N15. Do you currently rent or own your home?
Own
Rent
Occupied without paying monetary rent

N16. Does anyone in your family have a working
cell phone?
Yes
No

N17. Is there at least one telephone inside your
home that is currently working and is not a
cell phone?
Yes
No

N20. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
Yes
No

N21. Because of a physical, mental, or emotional
condition, do you have serious difficulty
concentrating, remembering, or making
decisions?
Yes
No

N22. Do you have serious difficulty walking or
climbing stairs?
Yes
No

N23. Do you have difficulty dressing or bathing?
Yes
No

N18. Thinking about members of your family living N24. Because of a physical, mental, or emotional
condition, do you have difficulty doing
in this household, what is your combined
errands alone such as visiting a doctor’s
annual income, meaning the total pre-tax
office or shopping?
income from all sources earned in the past
year?
Yes
$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

N19. Are you deaf or do you have serious
difficulty hearing?
Yes
No

No

N25. About how long did it take you to complete
the survey?
Write a number in one box below.
Minutes

Hours

N26. At which of the following types of addresses
does your household currently receive
residential mail?
MarkX 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.)

18

Thank you!
Please return this questionnaire in the postage-paid envelope within 2 weeks.
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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