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EPID

410 Principles of Epidemiology

Homework 3: Example Survey

1. What is your age?


_ _ years

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

3. Which one or more of the following would you say is your race? Check all that apply.
o White
o Black or African American
o Asian
o Native Hawaiian or Other Pacific Islander
o American Indian or Alaska Native

4. Are you currently?
o Employed for wages
o Self-employed
o Out of work for more than 1 year
o Out of work for less than 1 year
o A Homemaker
o A Student
o Retired
o Unable to work

5. Do you own or rent your home?
o Own
o Rent
o Other arrangement
o Dont know / Not sure






6. Would you say that in general your health is -
o Excellent
o Very Good
o Good
o Fair
o Poor

7. Now thinking about your physical health, which includes physical illness and injury,
for how many days during the past 30 days was your physical health not good?
__ __ Number of days (Please answer between 0-30)

8. 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?
__ __ Number of days (Please answer between 0-30)

9. (Ever told) you have a depressive disorder, including depression, major depression,
dysthymia, or minor depression?
o Yes
o No
o Dont know / Not sure

10. 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?
__ __ Number of days (Please answer between 0-30)

11. 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?
o Yes
o No
o Dont know / Not sure

12. During the past 30 days, for about how many days have you felt very healthy and
full of energy?
__ __ Number of days (Please answer between 0-30)




13. 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?
o Within the past year (anytime less than 12 months ago)
o Within the past 2 years (1 year, but less than 2 years ago)
o Within the past 5 year (2 years, but less than 5 years ago)
o 5 or more years ago
o Dont know/Not sure
o Never

14. In the past 12 months, was there any time when you did NOT have ANY health
insurance or coverage?
o Yes
o No
o Dont know/Not sure

15. Was there a time in the past 12 months when you needed to see a doctor, but count
not because of cost?
o Yes
o No
o Dont know/Not sure


Source: All questions from SC BRFSS 2012

Link: http://www.scdhec.gov/hs/epidata/BRFSS/Quest/2012.pdf