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Sex: Male Female

General Health: Excellent Very Good Good Fair Poor

Physical Health Days:

Mental Health Days:

Last Checkup Time: 5 or more years ago Within past 2 years (1 year but less than 2 years ago) Within past 5 years (2 years but less than 5 years ago) Within past year (anytime less than 12 months ago)

Physical Activities: Yes No

Sleep Hours:

Removed Teeth: Yes No

Had Angina: Yes No

Had Stroke: Yes No

Had Asthma: Yes No

Had Skin Cancer: Yes No

Had COPD: Yes No

Had Depressive Disorder: Yes No

Had Kidney Disease: Yes No

Had Arthritis: Yes No

Had Diabetes: Yes No

Deaf or hard of hearing: Yes No

Blind or Vision difficulty: Yes No

Do you Smoke?: Current smoker - now smokes every day Current smoker - now smokes some days Former Smoker Never Smoked

Race Ethnicity Category: Black only, Non-Hispanic Hispanic Multiracial, Non-Hispanic Other race only, Non-Hispanic White only, Non-Hispanic

Age Category: Age 25 to 29 Age 30 to 34 Age 35 to 39 Age 18 to 24 Age 40 to 44 Age 45 to 49 Age 50 to 54 Age 55 to 59 Age 60 to 64 Age 65 to 69 Age 70 to 74 Age 75 to 79 Age 80 or older

Height in Meters:

Weight in Kilograms:

BMI:

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