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2011-2012 Survey Questionnaires

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 - 189 KB]
Screener Module 1 (Spanish)
This is the same module in Spanish.
[PDF - 122 KB]
Screener Module 2
This establishes the relationship of everyone in the household to everyone else in the household.
[PDF - 204 KB]
Screener Module 2 (Spanish)
This is the same module in Spanish.
[PDF - 136 KB]

Family Questionnaire

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

Questionnaire Name Document
Demographic Background [PDF - 41 KB]
Occupation [PDF - 14 KB]
Housing Characteristics [PDF - 11 KB]
Smoking [PDF - 15 KB]
Consumer Behavior [PDF - 20 KB]
Income [PDF - 104 KB]
Food Security [PDF - 45 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 - 26 KB]
Audiometry [PDF - 45 KB]
Blood Pressure [PDF - 32 KB]
Cardiovascular Disease [PDF - 23 KB]
Chemical Senses - Taste and Smell [PDF - 39 KB]
Demographic [PDF - 86 KB]
Dermatology [PDF - 27 KB]
Diabetes [PDF - 56 KB]
Dietary Supplements and Prescription Medication [PDF - 130 KB]
Dietary Behavior [PDF - 71 KB]
Early Childhood [PDF - 24 KB]
Health Insurance [PDF - 45 KB]
Hospital Utilization and Access to Care [PDF - 35 KB]
Immunization [PDF - 25 KB]
Kidney Conditions [PDF - 21 KB]
Medical Conditions [PDF - 87 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]
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]
Drugs Use [PDF -69 KB]
Pubertal Maturation [PDF - 35 KB]
Sexual Behavior [PDF - 133 KB]
Tobacco Use [PDF - 59 KB]

Computer Assisted Personal Interview (CAPI) Questionnaire

Questionnaire Name Document
Alcohol Use [PDF - 26 KB]
Creatine Kinase [PDF - 26 KB]
Current Health Status [PDF - 25 KB]
Depression Screen [PDF - 29 KB]
Kidney [PDF - 30 KB]
Pesticide Use [PDF - 16 KB]
Physical Activity [PDF - 64 KB]
Reproductive Health [PDF - 89 KB]
Tobacco [PDF - 34 KB]
Volatile Toxicants Use [PDF - 28 KB]
Weight History [PDF - 36 KB]

Special Questionnaire

Questionnaire Name Document
Flexible Consumer Behavior Survey (FCBS Module) [PDF - 127 KB]

Dietary

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