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Question

Answer

1

Sex

- Male Female

2

Age

3

Height (without shoes)

feet   inches

4

Weight (without shoes)

pounds

5

Body frame size

- Small Medium Large

6

Have you ever been told that you have diabetes  (or sugar diabetes)?

- Yes No

7

Are you now taking medicine for high blood pressure?

- Yes No

8

What is your blood pressure now?

systolic
diastolic

9

If you do not know the numbers, how would you describe your blood pressure?

- High Normal or Low Don't Know

10

What is your TOTAL cholesterol level (based on a blood test)?

mg/dl

11

What is your HDL cholesterol (based on a blood test)?

mg/dl

12

How many cigars do you usually smoke per day?

cigars per day

13

How many pipes of tobacco do you usually smoke per day?

pipes per day

14

How many times per day do you usually use smokeless tobacco? (Chewing tobacco, snuff, pouches, etc.)

times per day

15

CIGARETTE SMOKING
How would you describe your cigarette smoking habits?

- Never smoked Used to smoke Still smoke

16

STILL SMOKE
How many cigarettes a day do you smoke?

cigarettes per day

17

USED TO SMOKE
How many years has it been since you smoked cigarettes fairly regularly?

years

What was the average number of cigarettes per day that you smoked in the 2 years before you quit?

cigarettes per day

18

In the next 12 months, how many thousands of miles will you probably travel by each of the following?
(NOTE: U.S. average = 10,000 miles)

Miles by car, truck, or van

,000 miles

Miles by motorcycle

,000 miles

19

On a typical day, how do you USUALLY travel?

- Walk Bicycle Motorcycle Sub-compact or compact car Mid-size or full-size car Truck or van Bus, subway, or train Mostly stay at home

20

What percent of time do you usually buckle your safety belt when driving or riding?

percent

21

On the average, how close to the speed limit do you usually drive?

- Within 5 mph of limit 6 - 10 mph over limit 11 - 15 mph over limit More than 15 mph over limit

22

How many times in the last month did you drive or ride when the driver had perhaps too much alcohol to drink?

times last month

23

How many drinks of an alcholic beverage do you have in a typical week

Beer per week

bottles or cans of beer

Wine per week

glasses of wine

Wine coolers per week

wine coolers

Liquor per week

mixed drinks or shots

24

Women: At what age did you have your first menstrual period?

years old

25

Women: How old were you when your first child was born?

years old

26

Women: How many women in your natural family (mother and sisters only) have had breast cancer?

women

27

Women: How long has it been since your last breast x-ray (mammogram)?

- Less than 1 year ago 1 year ago 2 years ago 3 or more years ago Never

28

Women: Have you had a hysterectomy operation?

- Yes No

29

Women: How long has it been since you had a pap smear test?

- Less Than 1 ago 1 year ago 2 years ago 3 or more years ago Never

*30

Women: How often do you examine your breasts for lumps?

- Monthly Once every few months Rarely or never

*31

Women: About how long has it been since you had your breasts examined by a physician or nurse?

- Less than 1 year ago 1 year ago 2 years ago 3 or more years ago Never

*32

Women: About how long has it been since you had a rectal exam?

- Less than 1 year ago 1 year ago 2 years ago 3 or more years ago Never

*33

Men: About how long has it been since you had a rectal or prostate exam?

- Less than 1 year ago 1 year ago 2 years ago 3 or more years ago Never

*34

How many times in the last year did you witness or become involved in a violent fight or attack where there was a good chance of a serious injury to someone?

- 4 or more times 2 or 3 times 1 time or never Not sure

*35

Considering your age, how would you describe your overall physical health?

- Excellent Good Fair Poor

*36

In an average week, how many times do you engage in physical activity (exercise or work which lasts at least 20 minutes without stopping and which is hard enough to make you breath heaver or your heart beat faster)?

- Less than 1 time per week 1 or 2 times per week At least 3 times per week

*37

If you ride a motorcycle or all-terrain vehicle (ATV), what percent of the time do you wear a helmet?

- 75% - 100% 25% - 74% Less than 25% Does not apply to me

*38

Do you eat some food every day that is high in fiber, such as whole grain bread, cereal, fresh fruits or vegetables?

- Yes No

*39

Do you eat foods every day that are high in cholesterol or fat, such as fatty meat, cheese, fried foods, or eggs?

- Yes No

*40

In general, how satisfied are you with your life?

- Mostly satisfied Partly satisfied Not satisfied

*41

Have you suffered a personal loss or misfortune in the past year that had a serious impact on your life? (For example, a job loss, disability, separation, jail term, or the death of someone close to you)

- Yes, 1 serious loss or misfortune Yes, 2 or more No

*42

Race

- Alaska native Aleutian American Indian Asian Black Eskimo Pacific Islander White Other Don't know

Are you of hispanic origin, such as Mexican-American, Puerto Rican, or Cuban?

- Yes No

*43

What is the highest grade you completed in school?

- Grade school or less Some high school High school graduate Some college College graduate Post graduate or professional degree

Please select the Oklahoma county you work in

- Adair Alfalfa Atoka Beaver Beckham Blaine Bryan Caddo Canadian Carter Cherokee Choctaw Cimarron Cleveland Coal Comanche Cotton Craig Creek Custer Delaware Dewey Ellis Garfield Garvin Grady Grant Greer Harmon Harper Haskell Hughes Jackson Jefferson Johnston Kay Kingfisher Kiowa Latimer Leflore Lincoln Logan Love Major Marshall Mayes Mcclain Mccurtain Mcintosh Murray Muskogee Noble Nowata Okfuskee Oklahoma Okmulgee Osage Ottawa Pawnee Payne Pittsburg Pontotoc Pottawatomie Pushmataha Roger Mills Rogers Seminole Sequoyah Stephens Texas Tillman Tulsa Wagoner Washington Washita WoodsWoodward

H44

Which of the responses best describes the smoking policy for areas in which employees work?

- Not allowed in any work area Allowed in some work areas Allowed in all work areas I am not employed

H45

Have you ever tried or experimented with cigarette smoking, even a few puffs? If no, please skip to question 55.

- Yes No

H46

About how old were you when you smoked your first cigarette?

- 13 or younger 14 to 19 20 or older Don't remember Never smoked

H47

About how old were you when you first started smoking cigarettes fairly regularly?

- 13 or younger 14 to 19 20 or older Don't remember Never smoked

H48

Do you now smoke cigarettes every day, some days, or not at all? If you answered not at all, please skip to question 55.

- Every day Some days Not at all

H49

What brand do you usually smoke?

- Benson and Hedges Camel Generic Kent Kool Marlboro Merit Newport Pall Mall Salem Virginia Slims Winston Other Dont Smoke

H50

How much do you usually pay for a pack of cigarettes?

- < $2.00 $2.00 - $3.00 More than $3.00 Don't know Don't smoke

H51

If the price per pack of all cigarettes went up by 25 cents, what would you most likely do? Would you switch to a cheaper brand, smoke fewer cigarettes, try to quit smoking, or would you not change your smoking behavior?

- Switch to a cheaper brand Smoke fewer cigarettes Try to quit smoking Not change

H52

What if the price went up by $0.50 cents?

- Switch to a cheaper brand Smoke fewer cigarettes Try to quit smoking Not change

H53

What if the price went up by one dollar?

- Switch to a cheaper brand Smoke fewer cigarettes Try to quit smoking Not change

H54

If you smoke, do you want to quit?

- Yes No Don't Smoke

H55

How much additional tax on a  pack of cigarettes would you be willing to support if all the money raised was used to fund programs aimed at preventing smoking among children, and other health care programs? What is the highest additional tax you are willing to support?

- $0.25 a pack $0.50 a pack $0.75 a pack $1.00 a pack No tax increase Don't know / not sure

H56

Do you use forms of tobacco other than cigarettes? If you answered no, skip to question 59.

- Yes No

H57

Do you use chewing tobacco every day, some days, or not at all?

- Every day Some days Not at all

H58

Have you ever used snuff, such as Skoal, Skoal Bandits, or Copenhagen?

- Yes No

H59

What is the risk of heart attack or death for non-smoking women regularly exposed to passive smoke either in their workplace or in their home?

- No risk 30% 90% 46% 10%

H60

About how many chemicals are found in tobacco smoke?

- 43 100 500 4,000 Don't know

H61

When tobacco is smoked, the resulting product that goes into the air is called:

- Side stream smoke Environmental tobacco smoke (ETS) Passive smoke Secondhand smoke All of the above

H62

Children exposed to secondhand smoke are at risk:

- because their bodies are developing of hindering growth of their lungs of having effects last a lifetime of developing respiratory diseases All of the above

H63

Do you believe tobacco use causes cancer?

- Yes No Don't know

H64

Do you believe anti-smoking ads are effective in discouraging young people not to begin smoking?

- Yes No Don't know

H65

Do you believe anti-smoking ads are effective in helping smokers quit smoking?

- Yes No Don't know

H66

How annoying do you find other people's smoking? Would you say not annoying at all, a little annoying, very annoying, or extremely annoying?

- Not annoying at all A little annoying Moderately annoying Very annoying Extremely annoying

H67

Are you troubled by pain, aching, or stiffness in your joints or have you ever been told by a doctor that you have any of the conditions listed here: arthritis, osteoarthritis, degenerative arthritis, rheumatoid arthritis, fibromyalgia, lupus, gout, and other related rheumatic conditions including some autoimmune diseases?

- Yes No

H68

During the past 30 days, how many days of work have you missed because of arthritis or pain, stiffness, or aching of your joints (e.g. knee, hip, shoulder, elbow, fingers, etc.)?

- None 1 day 2 or 3 days A week More than a week

H69

Do you want more information about arthritis, rheumatoid arthritis, fibromyalgia, lupus, gout, and other related rheumatic conditions as well as chronic aches and pains in the joints?

- Yes No