National Health and Nutrition Examination Survey

NHANES 2011-2012 Questionnaire Instruments

Questionnaires are administered to NHANES participants both at home and in the MECs. 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 - 75 KB]
Screener Module 1 (Spanish)
This is the same module in Spanish.
[PDF - 121 KB]
Screener Module 2
This establishes the relationship of everyone in the household to everyone else in the household.
[PDF - 78 KB]
Screener Module 2 (Spanish)
This is the same module in Spanish.
[PDF - 135 KB]

Family Questionnaire

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

Questionnaire Name Document
Consumer Behavior [PDF - 19 KB]
Demographic Background [PDF - 40 KB]
Family Questionnaire Hand Cards [PDF - 42 KB]
Food Security [PDF - 45 KB]
Housing Characteristics [PDF - 10 KB]
Income [PDF - 146 KB]
Occupation [PDF - 13 KB]
Smoking [PDF - 14 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 - 25 KB]
Audiometry [PDF - 45 KB]
Blood Pressure [PDF - 31 KB]
Cardiovascular Disease [PDF - 22 KB]
Chemical Senses - Taste and Smell [PDF - 38 KB]
Demographic [PDF - 86 KB]
Dermatology [PDF - 27 KB]
Diabetes [PDF - 55 KB]
Dietary Behavior [PDF - 70 KB]
Dietary Supplements and Prescription Medication [PDF - 129 KB]
Early Childhood [PDF - 23 KB]
Health Insurance [PDF - 45 KB]
Hospital Utilization and Access to Care [PDF - 35 KB]
Immunization [PDF - 25 KB]
Kidney Conditions [PDF - 20 KB]
Medical Conditions [PDF - 86 KB]
Occupation [PDF - 81 KB]
Oral Health [PDF - 36 KB]
Physical Activity and Physical Fitness [PDF - 62 KB]
Physical Functioning [PDF - 63 KB]
Respiratory Health and Disease [PDF - 36 KB]
Sample Person Questionnaire Hand Cards [PDF - 520 KB]
Sleep Disorders [PDF - 18 KB]
Smoking and Tobacco Use [PDF - 41 KB]
Tuberculosis [PDF - 24 KB]
Weight History [PDF - 55 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 Use [PDF - 22 KB]
Drug Use [PDF - 68 KB]
Pubertal Maturation [PDF - 35 KB]
Sexual Behavior [PDF - 132 KB]
Tobacco Use [PDF - 59 KB]

Computer Assisted Personal Interview (CAPI) Questionnaire

Questionnaire Name Document
Alcohol Use [PDF - 25 KB]
Creatine Kinase [PDF - 26 KB]
Current Health Status [PDF - 25 KB]
Depression Screen [PDF - 29 KB]
Kidney [PDF - 29 KB]
Pesticide Use [PDF - 16 KB]
Physical Activity [PDF - 63 KB]
Reproductive Health [PDF - 88 KB]
Tobacco [PDF - 34 KB]
Volatile Toxicants Use [PDF - 28 KB]
Weight History [PDF - 36 KB]

Special Follow-up Questionnaires

Questionnaire Name Document
Flexible Consumer Behavior Survey (FCBS Module) [PDF - 126 KB]


Questionnaire Name Document
24-Hour Dietary Supplement and Antacids Use [PDF - 163 KB]
Dietary Recall [PDF - 41 KB]
Measuring Guides for the Dietary Recall Interview