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2003-2004 Survey Questionnaires

Questionnaires are administered to NHANES participants both at home and in the trailers. The questionnaires and a brief description of each section follows.

Screener Modules

Module Name Document
Screener Module 1
This is administered on the doorstep. This set of questions determines if anyone in the household is eligible to be in the sample.
[PDF - 615.1 KB]
Screener Module 2
This establishes the relationship of everyone in the household to everyone else in the household.
[PDF - 32 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 - 89.4 KB]
Food Security [PDF - 95.3 KB]
Housing Characteristics [PDF - 49.2 KB]
Income [PDF - 159 KB]
Pesticide Use [PDF - 45.6 KB]
Smoking [PDF - 30.4 KB]
Tracking and Tracing [PDF - 47.8 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 - 53.1 KB]
Audiometry [PDF - 44.7 KB]
Balance [PDF - 53.7 KB]
Blood Pressure [PDF - 72.9 KB]
Cardiovascular Disease [PDF - 51.5 KB]
Cardiovascular Fitness [PDF - 37.6 KB]
Demographics Information [PDF - 113.3 KB]
Dermatology [PDF - 60.1 KB]
Diabetes [PDF - 51.8 KB]
Dietary Supplements and Prescription Medication [PDF - 193.7 KB]
Diet Behavior and Nutrition [PDF - 103.1 KB]
Diet Behavior and Nutrition (Food Security Questions) [PDF - 16 KB]
Dust Collection [PDF - 97.3 KB]
Early Childhood [PDF - 52.9 KB]
Health Insurance [PDF - 98.6 KB]
Hospital Utilization and Access to Care [PDF - 56.4 KB]
Immunization [PDF - 34.9 KB]
Introduction and Verification [PDF - 51.6 KB]
Kidney Conditions [PDF - 47.3 KB]
Medical Conditions [PDF - 159.1 KB]
Miscellaneous Pain [PDF - 51.1 KB]
Occupation [PDF - 211.4 KB]
Oral Health [PDF - 61 KB]
Osteoporosis [PDF - 66.2 KB]
Physical Activity and Physical Fitness [PDF - 112.4 KB]
Physical Functioning [PDF - 84 KB]
Respiratory Health and Disease [PDF - 33 KB]
Respondent Selection [PDF - 89 KB]
Smoking and Tobacco Use [PDF - 104.8 KB]
Social Support [PDF - 38.5 KB]
Vision [PDF - 75.3 KB]
Weight History [PDF - 67.2 KB]

Post-Examination Questionnaires

Questionnaire Name Document
Food Frequency (formerly called Food Propensity): Mailed to Respondent [PDF - 1.1 MB]
Hepatitis Follow-up: Telephone Interview [PDF - 363 KB]
Prostate Follow-up: Telephone Interview [PDF - 72.6 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 - 188 KB]

Columbia University Diagnostic Schedule for Children (CDISC)

Questionnaire Name Document
General Documentation [PDF - 148 KB]
DISC Interviewer Manual [PDF - 470 KB]
DISC Telephone Interviewer Manual [PDF - 128 KB]
Variable List [PDF - 3.3 MB]
Attention Deficit Hyperactivity Disorder (2000-2004) (Parent Questionnaire) [PDF - 446 KB]
Conduct Disorder (2000-2004) (Parent Questionnaire) [PDF - 572 KB]
Major Depression/Dysthymic Disorder (2000-2004) (Youth Questionnaire) [PDF - 529 KB]
Major Depression/Dysthymic Disorder (2000-2004) (Parent Questionnaire) [PDF - 528 KB]
Eating Disorders (2000-2004) (Youth Questionnaire) [PDF - 309 KB]
Eating Disorders (2000-2004) (Youth Questionnaire with Height and Weight Chart) [PDF - 35 KB]
Eating Disorders (2000-2004) (Parent Questionnaire) [PDF - 300 KB]
Elimination Disorders (2000-2004) (Parent Questionnaire) [PDF - 309 KB]
Generalized Anxiety Disorder (1999-2004) (Youth Questionnaire) [PDF - 256 KB]
Panic (1999-2004) (Youth Questionnaire) [PDF - 250 KB]

MEC ACASI and CAPI Questionnaires

Audio computer assisted personal 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 Personal Self Interview (ACASI) Questionnaire

Questionnaire Name Document
Alcohol (ages 12-19) [PDF - 56.5 KB]
DISC Predictive Scale - Youth Conduct Disorder (ages 12-19) [PDF - 62.1 KB]
Drugs (ages 12-59) [PDF - 56.9 KB]
Food Security (ages 12-15) [PDF - 35.5 KB]
Kidney Conditions (Prostate) [PDF - 95.7 KB]
Sexual Behavior (ages 14-59) [PDF - 89.1 KB]
Tobacco [PDF - 69.4 KB]

Computer Assisted Personal Interview (CAPI) Questionnaire

Questionnaire Name Document
Alcohol (ages 20+) [PDF - 40.1 KB]
Current Health Status [PDF - 43.1 KB]
Kidney [PDF - 44.1 KB]
Physical Activity [PDF - 89.7 KB]
Reproductive Health [PDF - 226.1 KB]
Respondent Information [PDF - 36.4 KB]
Tobacco (ages 20+) [PDF - 62.4 KB]

Dietary

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