National Health and Nutrition Examination Survey

NHANES 2003-2004 Questionnaire Instruments

Questionnaires are administered to NHANES participants both at home and in the mobile examination centers (MECs). The questionnaires and a brief description of each section follows.

Screener Module: In-person/Telephone Instrument

The following questionnaires are used by field interviewers to collect screener information during the in-person interview on the doorstep or through a telephone interview with an adult household member.

Module Name	Document
Screener Module 1 This set of questions determines if anyone in the household is eligible to be in the sample.	[PDF - 647 KB]
Screener Module 2 This set of questions establishes the relationship of everyone in the household to each other.	[PDF - 31 KB]

Family Questionnaire

Household and family level information is collected here. The sections are labeled to reflect content.

Questionnaire Name	Document
Demographic Background/Occupation	[PDF - 66 KB]
Food Security	[PDF - 68 KB]
Housing Characteristics	[PDF - 30 KB]
Income	[PDF - 99 KB]
Pesticide Use	[PDF - 35 KB]
Smoking	[PDF - 20 KB]

Sample Person Questionnaire

Individual level information on participants is collected here. The sections are labeled to reflect content. Please note that the Medical Conditions section covers many subject areas.

Questionnaire Name	Document
Acculturation	[PDF - 40 KB]
Audiometry	[PDF - 34 KB]
Balance	[PDF - 40 KB]
Blood Pressure	[PDF - 48 KB]
Cardiovascular Disease	[PDF - 38 KB]
Cardiovascular Fitness	[PDF - 29 KB]
Demographics Information	[PDF - 90 KB]
Dermatology	[PDF - 39 KB]
Diabetes	[PDF - 38 KB]
Diet Behavior and Nutrition	[PDF - 49 KB]
Diet Behavior and Nutrition (Food Security Questions)	[PDF - 13 KB]
Dietary Supplements and Prescription Medication	[PDF - 110 KB]
Dust Collection	[PDF - 65 KB]
Early Childhood	[PDF - 36 KB]
Health Insurance	[PDF - 59 KB]
Hospital Utilization and Access to Care	[PDF - 40 KB]
Immunization	[PDF - 27 KB]
Introduction and Verification	[PDF - 40 KB]
Kidney Conditions	[PDF - 35 KB]
Medical Conditions	[PDF - 90 KB]
Miscellaneous Pain	[PDF - 37 KB]
Occupation	[PDF - 82 KB]
Oral Health	[PDF - 35 KB]
Osteoporosis	[PDF - 48 KB]
Physical Activity and Physical Fitness	[PDF - 74 KB]
Physical Functioning	[PDF - 58 KB]
Respiratory Health and Disease	[PDF - 33 KB]
Smoking and Tobacco Use	[PDF - 57 KB]
Social Support	[PDF - 30 KB]
Vision	[PDF - 66 KB]
Weight History	[PDF - 38 KB]

Post-Examination Questionnaires

Questionnaire Name	Document
Food Frequency (formerly called Food Propensity): Mailed to Respondent	[PDF - 1.05 MB]
Hepatitis Follow-up: Telephone Interview	[PDF - 365 KB]
Prostate Follow-up: Telephone Interview	[PDF - 44 KB]

Mental Health Questionnaires

This questionnaire was conducted in the Mobile Examination Center (MEC).

Questionnaire Name	Document
Composite International Diagnostic Interview consist of the following: Generalized Anxiety Disorder Module Major Depression Module Interview Panic Disorder Module	[PDF - 187 KB]

Columbia University Diagnostic Schedule for Children (CDISC)

Questionnaire Name	Document
Attention Deficit Hyperactivity Disorder (2000-2004) (Parent Questionnaire)	[PDF - 446 KB]
Conduct Disorder (2000-2004) (Parent Questionnaire)	[PDF - 572 KB]
DISC Interviewer Manual	[PDF - 470 KB]
DISC Telephone Interviewer Manual	[PDF - 128 KB]
Eating Disorders (2000-2004) (Parent Questionnaire)	[PDF - 299 KB]
Eating Disorders (2000-2004) (Youth Questionnaire with Height and Weight Chart)	[PDF - 35 KB]
Eating Disorders (2000-2004) (Youth Questionnaire)	[PDF - 309 KB]
Elimination Disorders (2000-2004) (Parent Questionnaire)	[PDF - 309 KB]
General Documentation	[PDF - 147 KB]
Generalized Anxiety Disorder (1999-2004) (Youth Questionnaire)	[PDF - 256 KB]
Major Depression/Dysthymic Disorder (2000-2004) (Parent Questionnaire)	[PDF - 528 KB]
Major Depression/Dysthymic Disorder (2000-2004) (Youth Questionnaire)	[PDF - 529 KB]
Panic (1999-2004) (Youth Questionnaire)	[PDF - 250 KB]
Variable List	[PDF - 409 KB]

MEC ACASI and CAPI Questionnaires

Audio computer-assisted self-interview (ACASI) and computer-assisted personal interview (CAPI) questionnaires are administered in the MEC. During the visit to the examination center additional questions are administered that cover more sensitive areas such as reproductive health and illegal drug use. The sections are labeled to reflect content.

Audio Computer-Assisted Self-Interview (ACASI) Questionnaire

Questionnaire Name	Document
Alcohol (ages 12-19)	[PDF - 50 KB]
DISC Predictive Scale - Youth Conduct Disorder (ages 12-19)	[PDF - 57 KB]
Drugs (ages 12-59)	[PDF - 44 KB]
Food Security (ages 12-15)	[PDF - 27 KB]
Kidney Conditions (Prostate)	[PDF - 81 KB]
Sexual Behavior (ages 14-59)	[PDF - 60 KB]
Tobacco	[PDF - 42 KB]

Computer-Assisted Personal Interview (CAPI) Questionnaire

Questionnaire Name	Document
Alcohol (ages 20+)	[PDF - 30 KB]
Current Health Status	[PDF - 32 KB]
Kidney	[PDF - 34 KB]
Physical Activity	[PDF - 59 KB]
Reproductive Health	[PDF - 122 KB]
Tobacco (ages 20+)	[PDF - 36 KB]

Dietary

These questions on dietary intakes and dietary supplement uses are asked to participants after their visits to the mobile examination center through telephone interviews.

Questionnaire Name	Document
Dietary Recall	[PDF - 103 KB]
Measuring Guides for the Dietary Recall Interview

Content source: CDC/National Center for Health Statistics