Start
nshd_77_q
STRICTLY CONFIDENTIAL
1977
H6
NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
(Medical Research Council)

What is your usual address now?

(if no change write SAME)

Generic text

What was your usual address exactly one year ago?

(If same as now write SAME)

Generic text
HOW TO COMPLETE THIS QUESTIONNAIRE
Please work through the form writing answers in the box or space provided or putting a ring round the number next to the right answer.
Please complete the form yourself. If you have any difficulty you should get someone to help you, but it is important that the answers should be yours.
When you have answered the questions, please post the form to us in the pre-paid envelope.
CONFIDENTIALITY
All personal information is strictly confidential and is used only for statistical purposes. We never mention anyone by name in any reports we write.
FAMILY INFORMATION

When we last contacted you, you were ... Have there been any changes since then? Have you been married or re-married, separated or divorced, or have you been widowed?

1
Yes
0
No
If 'yes'
qc_1_a == 1

Are you now

1
married
2
widowed
3
separated
4
divorced

Please give dates of all the changes that have happened. Date of marriages

Generic date
Generic date 2

Please give dates of all the changes that have happened. Date(s) separated

Generic date
Generic date 2

Please give dates of all the changes that have happened. Date(s) divorced

Generic date
Generic date 2

Please give dates of all the changes that have happened. Date widowed

Generic date

Is your own mother alive?

1
Yes
0
No
If 'no'
qc_2_a == 0

When did she die?

Date of death

Where was she then living? (town and county)

Generic text

If she died in hospital please give its name (and town)

Generic text

ls your own father alive?

1
Yes
0
No
If 'no'
qc_3_a == 0

When did he die?

Date of death

Where was he then living? (town and county)

Generic text

If he died in hospital please give its name (and town)

Generic text

The last child you told us about was ... born on ... Have you had any children since then?

1
Yes
0
No
If 'yes'
qc_4_a == 1
Please give details of all later births:
Name Sex Date of birth Name of hospital or address where born If not still alive give date of death
Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death
1
2
3
4
5
6

Are you/is your wife pregnant now?

1
Yes
0
No
If 'yes'
qc_5_a == 1

When is the baby due?

Generic date

Would you say that in your home and personal life you are under:

1
little or no nervous strain
2
some nervous strain
3
severe nervous strain
If 'some' or 'severe'
qc_6_a == 2 || qc_6_a == 3

could you say what is the cause of strain?

Generic text

How does it affect you?

Generic text
HEALTH

The last accident you told us about was ... Since then have you had any accident in which you broke a bone, were badly cut or bruised, were burnt or scalded, or injured by chemicals or a foreign body?

1
Yes
0
No
If 'yes'
qc_7_a == 1
_accident < 4 _accident < 4

Type of injury

Generic text

Part of body

Generic text

Date, month, year

Generic date

Treatment (hospital inpatient, outpatient, own doctor, works doctor, any other treatment)

Generic text

How and where it happened

Generic text

Any disability

Generic text

The last hospital admission you told us about was ... Have you been a hospital inpatient since then?

1
Yes
0
No
If 'yes'
qc_8_a == 1
please give details of all admissions below
Name of hospital (and town) Date of admission (month, year) Reason for admission Length of stay (days) Name of doctor in charge of case
Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text
1
2
3
4
5

The last outpatient visit you told us about was ... Have you attended an outpatient or other clinic since?

1
Yes
0
No
If 'yes'
qc_9_a == 1
please give details
Name of hospital or clinic (and town) Reason for attendance Type of clinic (e.g. asthma, gynaecological) Date of first visit (month, year)
Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text
1
2
3

Apart from visits to a hospital or clinic, have you seen a doctor since this time last year?

1
Yes
0
No
If 'yes'
qc_10_a == 1
_doctor_visit < 4 _doctor_visit < 4

Why did you go?

Generic text

What did the doctor say was wrong with you?

Generic text

Dates

Generic date

Do you regularly take any medicine, pills or tablets (or have regular injections)?

Note: please enter details of the contraceptive pill at question 12 below

1
Yes
0
No
if 'yes'
qc_11_a == 1
_medications < 3 _medications < 3

What do you take it for?

Generic text

When did you start taking it?

Generic text

Who prescribed (or suggested) it? (Doctor, chemist etc)

Generic text

Name of preparation

Please check label of bottle etc.

Generic text

Dosage

Please check label of bottle etc.

Generic text
WOMEN ONLY

Have you ever taken the contraceptive pill?

1
Yes
0
No
If 'yes'
qc_12_a == 1

Can you give us some idea of how long you have actually used the pill? ... months ... years

(please add together all the separate times you have been on the pill)

How many I
How many I 2

What is the name of the pill you have taken most recently?

Generic text

Have you been using the pill during the last month?

1
Yes
0
No
If 'no'
qc_12_d == 0

When did you last stop using the pill?

Generic date
EMPLOYMENT

Have you had a long spell (a month or more) off work through illness since March 1972?

1
Yes
0
No
8
Not worked since March 1972
If 'yes'
qc_13_a == 1
_illness < 3 _illness < 3

Date started (month, year)

Generic date

What was wrong with you?

Generic text

Time off work

Duration

Have you had a long spell (a month or more) off work because you were unemployed and looking for a job since March 1972?

1
Yes
0
No
If 'yes'
qc_14_a == 1
_unemployed < 3 _unemployed < 3

Dates (month, year)

Generic date

Length of time unemployed

Duration

How long did you register as unemployed?

Duration

Are you now

1
working full-time
2
working part-time
3
a full-time housewife
4
unemployed
*
or doing something else? (please explain)
Generic text
The last job you told us about is written in red below. Please give details of all jobs (including promotions or changes within the firm) you have had since then, putting in any periods you have had off work (e.g. as a housewife or student). If there have been no changes at all, put 'still there'.
Type of job (i.e. what you do?) Full or part time? Are you self-employed Type of firm (i.e. what do they do?) Date started month, year Date left month, year
Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text
1
2
3
4
5
6
IF YOU ARE NOT NOW IN PAID WORK OR IF YOU ARE NOW WORKING LESS THAN 8 HOURS A WEEK PLEASE, GO TO THE QUESTIONS ON SMOKING (question 23 on the next page)
Else
If self employed

How many do you employ? (apart from yourself and your own family)

0
None
1
1 or 2
2
3 - 5
*
6 or more (please give number)
How many I
If not self employed

How many people are employed by your firm? (at the branch at which you work) please give an estimate of the actual number ... approx

0
Less than 25
1
25 or more
How many I

Does your job involve supervising the work of others?

1
Yes
0
No
If 'yes'
qc_18_a == 1

What is your official status (if any)? (e.g. chargehand, foreman, manager)

Generic text

How many people do you supervise? Supervise all the work of ... people

How many I

How many people do you supervise? Supervise part of the work of ... people

How many I

How many hours a week do you usually work including overtime? ... hours at work

How many I

How many hours a week do you usually work including overtime? ... hours at home

How many I

Do you ever do night or shift work? (in your present employment)

1
Yes
0
No
If 'yes'
qc_19_b == 1

On average, how many nights a month do you work after midnight? ... nights

Nights in month

How many such nights do you work at a stretch? ... nights

Nights in month

On average, how much do you earn a week? (including overtime and other payment) before deductions £ ... ... p.

How many F

Would you say that in your work, you are under:

3
severe nervous strain
2
some nervous strain
1
little or no nervous strain
'if 'some' or 'severe'
qc_21_a == 2 || qc_21_a == 3

Could you say what is the main cause of strain?

Generic text

How does it affect you?

Generic text

Please would you write here a brief description of your present job and the responsibilities you have at work.

Long text
SMOKING
Please ring the codes that apply to you showing your past and present smoking habits.
Are you now

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

cigarettes
cigars
a pipe
If you have ever smoked cigarettes
qc_23_a$1;1 == 3||qc_23_a$1;1 == 2||qc_23_a$1;1 == 1

How far do/did you usually take the smoke in?

1
hold it in the mouth
2
to the back of the throat
3
partly in to the chest
4
deeply

When did you (last) give up cigarette smoking (for a month or more)?

0
never given it up
Generic date
regular smokers
qc_23_a$1;1 == 3

Over the past year, how many cigarettes a day have you usually smoked? ... cigarettes

How many I
ex-smokers
qc_23_a$1;1 == 1

How many cigarettes a day were you smoking before you gave up? ... cigarettes

How many I
HEIGHT AND WEIGHT

How tall are you (without shoes)? ... ft ... ins

How many I
Inches in foot

How much do you weigh (without clothes)? (if pregnant please give your weight before. this pregnancy) ... st ... lbs

How many I
Pounds in stone

How long ago was this weight checked on the scales? within the last ... weeks/month

How many I
1
today

What is your present waist measurement

1
Is this measured by a tape
2
estimated by the waist size of your skirt/trousers
SLEEP

During the last month or so have you been having any trouble with your sleep?

1
Yes
0
No
If 'yes'
qc_25_a == 1

What sort of trouble have you had? (ring more than one if necessary)

1
I have difficulty in getting off to sleep
2
I wake up in the night and can't get off to sleep again quickly
3
I have unpleasant dreams or nightmares
4
I wake up too early in the morning and stay awake
5
I sleep all night but still feel tired in the morning
*
Any other sort of trouble? (please describe)
Other
COUGH

Do you usually cough first thing in the morning in the winter?

1
Yes
0
No

Do you usually cough during the day or night in winter?

1
Yes
0
No
If 'yes' to (a) or (b)
qc_26_a == 1 || qc_26_b == 1

Do you cough like this on most days for as much as 3 months each winter?

1
Yes
0
No

During the past three years have you had any chest illness ( e.g. bronchitis, pneumonia) which has kept you off work or indoors for a week or more?

1
Yes
0
No
RHEUMATISM AND BACK PAIN

Have you ever had:- Arthritis or rheumatism of your joints? (arms, legs, hands, feet)

1
Yes
0
No

Have you ever had:- Trouble with your back?

1
Yes
0
No
If 'no' to both, please go to question 28 on the next page
qc_27_a_i == 0 && qc_27_a_ii == 0
Else

How many times have you had this trouble Arthritis or rheumatism

1
once or twice
2
several times
3
frequently

How many times have you had this trouble Trouble with your back

1
once or twice
2
several times
3
frequently

Which parts have been affected? Arthritis or rheumatism

Generic text

Which parts have been affected? Trouble with your back

Generic text

ls the trouble relieved by exercise? Arthritis or rheumatism

1
Yes
0
No

ls the trouble relieved by exercise? Trouble with your back

1
Yes
0
No

Did this trouble come on after an injury? Arthritis or rheumatism

1
Yes
0
No

Did this trouble come on after an injury? Trouble with your back

1
Yes
0
No

Have you had this trouble during the last 12 months? Arthritis or rheumatism

1
Yes
0
No

Have you had this trouble during the last 12 months? Trouble with your back

1
Yes
0
No

Have you had to stay away from work because of the trouble? Arthritis or rheumatism

1
yes, in the last 12 months
2
yes, earlier than this
0
No

Have you had to stay away from work because of the trouble? Trouble with your back

1
yes, in the last 12 months
2
yes, earlier than this
0
No

Have you seen a doctor about the trouble? Arthritis or rheumatism

1
yes, in the last 12 months
2
yes, earlier than this
0
No
If 'yes'
qc_27_h_i == 1 || qc_27_h_i == 2

What did he say was wrong? Arthritis or rheumatism

Generic text

Have you seen a doctor about the trouble? Trouble with your back

1
yes, in the last 12 months
2
yes, earlier than this
0
No
If 'yes'
qc_27_h_ii == 1 || qc_27_h_ii == 2

What did he say was wrong? Trouble with your back

Generic text

Do you ever get pain in the pit of your stomach? (in the area shown in green in the diagram)

1
Yes
0
No
If 'no' please go to question 29 below
qc_28_a == 0
Else

Have you had this pain during the last 12 months?

1
Yes
0
No

When did you first notice this pain? about ...weeks ago about ... months ago about ... years ago

How many I

Do you get this pain

1
once a year or less
2
several times a year
3
about once each month
4
several times a month

How long does the pain last?

Generic text

Does food ever make it better?

1
Yes
0
No
9
Don't know

Does food ever make it worse?

1
Yes
0
No
9
Don't know

Does the pain ever wake you at night?

1
Yes
0
No

Have you taken any medicine or tablets for this pain?

1
Yes
0
No
If 'yes'
qc_28_i == 1

What do you/did you take?

Generic text

Do they make the pain better?

2
Yes
1
Sometimes
0
No

Have you had to stay away from work because of the pain?

1
yes, in the last 12 months
2
yes, earlier than this
0
No

Have you consulted a doctor about the pain?

1
yes, in the last 12 months
2
yes, earlier than this
0
No
If 'yes'
qc_28_m == 1 || qc_28_m == 2

What did he say was wrong?

Generic text

If he did any special investigations, please tell us what they were:

Generic text
HEADACHE

Have you had a headache during the past 12 months?

1
Yes
0
No
If 'no' please turn to question 30 on the next page
qc_29_a == 0
Else

Are your headaches usually

1
fairly mild?
2
quite severe?
3
very severe?

How often do you get a headache?

1
once a year or less
2
several times a year
3
about once a month
4
several times a month

Are your headaches on one side only?

1
never
2
sometimes
3
usually
4
always

Before your get a headache, do you ever know one is coming?

1
Yes
0
No
If 'yes'
qc_29_e == 1

What do you notice?

Generic text

When you have a headache do you:

1
ever feel sick?
2
ever vomit?
0
no feelings of sickness

Have you ever consulted a doctor about the headache?

1
yes, in the last 12 months
2
yes, earlier than this
0
No
If 'yes'
qc_29_h == 1 || qc_29_h == 2

What did he say was wrong?

Generic text
SPORTS AND FITNESS

Do you think of yourself as being

1
very fit
2
fairly fit
3
not very fit
Please ring the codes below, indicating any sports or keep fit activities you take part in, and showing how often you do these things (during the season)
cs_q30_b-c_Y any others: (please describe) cs_dash cs_q30_b-c

1 - Seldom or never

2 - several times a year

3 - At least once a month

4 - At least once a week

swimming 1 -
swimming 2 -
swimming 3 -
cycling 1 -
cycling 2 -
cycling 3 -
squash, tennis or badminton 1 -
squash, tennis or badminton 2 -
squash, tennis or badminton 3 -
keep fit classes 1 -
keep fit classes 2 -
keep fit classes 3 -

Apart from these, is there anything else you do or avoid doing in order to keep fit? Please write here what you do and (if appropriate) how often.

Generic text

ls there any aspect of your health that you worry about, even though you may not have consulted a doctor about it?

1
Yes
0
No
If 'yes'
qc_30_e == 1

Please describe what worries you and say whether you have ever consulted a doctor about it.

Generic text

Has anything important happened to you in the last five years that we have not asked about? Please write here anything you wish to tell us.

Generic text

When we asked you about your health in 1972 you said you were suffering from ... Please give details of any treatment you received for the condition

Generic text

Are you troubled by it now?

1
Yes
0
No
If 'yes'
qc_32_c == 1

please give details

Generic text

Does it restrict your activities at home or work in anyway?

1
Yes
0
No
If 'yes'
qc_32_e == 1

please give details

Generic text

Today's date

Generic date
PLEASE CHECK THAT YOU HAVE ANSWERED ALL THE QUESTIONS
Please post the form directly to us in the special envelope
THANK YOU VERY MUCH FOR ALL YOUR HELP
End

nshd_77_q

STRICTLY CONFIDENTIAL
NATIONAL SURVEY OF HEALTH AND DEVELOPMENT
(Medical Research Council)
What is your usual address now?
Generic text
What was your usual address exactly one year ago?
Generic text
HOW TO COMPLETE THIS QUESTIONNAIRE
Please work through the form writing answers in the box or space provided or putting a ring round the number next to the right answer.
Please complete the form yourself. If you have any difficulty you should get someone to help you, but it is important that the answers should be yours.
When you have answered the questions, please post the form to us in the pre-paid envelope.
CONFIDENTIALITY
All personal information is strictly confidential and is used only for statistical purposes. We never mention anyone by name in any reports we write.

FAMILY INFORMATION

When we last contacted you, you were ... Have there been any changes since then? Have you been married or re-married, separated or divorced, or have you been widowed?
1
Yes
0
No
Are you now
1
married
2
widowed
3
separated
4
divorced
Please give dates of all the changes that have happened. Date of marriages
Generic date
Generic date 2
Please give dates of all the changes that have happened. Date(s) separated
Generic date
Generic date 2
Please give dates of all the changes that have happened. Date(s) divorced
Generic date
Generic date 2
Please give dates of all the changes that have happened. Date widowed
Generic date
Is your own mother alive?
1
Yes
0
No
When did she die?
Date of death
Where was she then living? (town and county)
Generic text
If she died in hospital please give its name (and town)
Generic text
ls your own father alive?
1
Yes
0
No
When did he die?
Date of death
Where was he then living? (town and county)
Generic text
If he died in hospital please give its name (and town)
Generic text
The last child you told us about was ... born on ... Have you had any children since then?
1
Yes
0
No

Please give details of all later births:

Name Sex Date of birth Name of hospital or address where born If not still alive give date of death
Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death Date of birthGeneric textGeneric textDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textDate of birthDate of deathGeneric textGeneric textGeneric textGeneric textGeneric textDate of deathGeneric textDate of birthGeneric textGeneric textDate of birthGeneric textDate of death
1
2
3
4
5
6
Are you/is your wife pregnant now?
1
Yes
0
No
When is the baby due?
Generic date
Would you say that in your home and personal life you are under:
1
little or no nervous strain
2
some nervous strain
3
severe nervous strain
could you say what is the cause of strain?
Generic text
How does it affect you?
Generic text

HEALTH

The last accident you told us about was ... Since then have you had any accident in which you broke a bone, were badly cut or bruised, were burnt or scalded, or injured by chemicals or a foreign body?
1
Yes
0
No

_accident < 4

Type of injury
Generic text
Part of body
Generic text
Date, month, year
Generic date
Treatment (hospital inpatient, outpatient, own doctor, works doctor, any other treatment)
Generic text
How and where it happened
Generic text
Any disability
Generic text
The last hospital admission you told us about was ... Have you been a hospital inpatient since then?
1
Yes
0
No

please give details of all admissions below

Name of hospital (and town) Date of admission (month, year) Reason for admission Length of stay (days) Name of doctor in charge of case
Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text Generic textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textGeneric textGeneric dateHow many IGeneric textGeneric textHow many IGeneric dateGeneric textGeneric dateGeneric textGeneric textHow many IGeneric textGeneric textHow many IGeneric textGeneric dateGeneric text
1
2
3
4
5
The last outpatient visit you told us about was ... Have you attended an outpatient or other clinic since?
1
Yes
0
No

please give details

Name of hospital or clinic (and town) Reason for attendance Type of clinic (e.g. asthma, gynaecological) Date of first visit (month, year)
Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text Generic dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric dateGeneric text
1
2
3
Apart from visits to a hospital or clinic, have you seen a doctor since this time last year?
1
Yes
0
No

_doctor_visit < 4

Why did you go?
Generic text
What did the doctor say was wrong with you?
Generic text
Dates
Generic date
Do you regularly take any medicine, pills or tablets (or have regular injections)?
1
Yes
0
No

_medications < 3

What do you take it for?
Generic text
When did you start taking it?
Generic text
Who prescribed (or suggested) it? (Doctor, chemist etc)
Generic text
Name of preparation
Generic text
Dosage
Generic text
Have you ever taken the contraceptive pill?
1
Yes
0
No
Can you give us some idea of how long you have actually used the pill? ... months ... years
How many I
How many I 2
What is the name of the pill you have taken most recently?
Generic text
Have you been using the pill during the last month?
1
Yes
0
No
When did you last stop using the pill?
Generic date

EMPLOYMENT

Have you had a long spell (a month or more) off work through illness since March 1972?
1
Yes
0
No
8
Not worked since March 1972

_illness < 3

Date started (month, year)
Generic date
What was wrong with you?
Generic text
Time off work
Duration
Have you had a long spell (a month or more) off work because you were unemployed and looking for a job since March 1972?
1
Yes
0
No

_unemployed < 3

Dates (month, year)
Generic date
Length of time unemployed
Duration
How long did you register as unemployed?
Duration
Are you now
1
working full-time
2
working part-time
3
a full-time housewife
4
unemployed
*
or doing something else? (please explain)
Generic text

The last job you told us about is written in red below. Please give details of all jobs (including promotions or changes within the firm) you have had since then, putting in any periods you have had off work (e.g. as a housewife or student). If there have been no changes at all, put 'still there'.

Type of job (i.e. what you do?) Full or part time? Are you self-employed Type of firm (i.e. what do they do?) Date started month, year Date left month, year
Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text Generic dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric dateGeneric textGeneric textGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric textGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric dateGeneric textGeneric text
1
2
3
4
5
6
How many do you employ? (apart from yourself and your own family)
0
None
1
1 or 2
2
3 - 5
*
6 or more (please give number)
How many I
How many people are employed by your firm? (at the branch at which you work) please give an estimate of the actual number ... approx
0
Less than 25
1
25 or more
How many I
Does your job involve supervising the work of others?
1
Yes
0
No
What is your official status (if any)? (e.g. chargehand, foreman, manager)
Generic text
How many people do you supervise? Supervise all the work of ... people
How many I
How many people do you supervise? Supervise part of the work of ... people
How many I
How many hours a week do you usually work including overtime? ... hours at work
How many I
How many hours a week do you usually work including overtime? ... hours at home
How many I
Do you ever do night or shift work? (in your present employment)
1
Yes
0
No
On average, how many nights a month do you work after midnight? ... nights
Nights in month
How many such nights do you work at a stretch? ... nights
Nights in month
On average, how much do you earn a week? (including overtime and other payment) before deductions £ ... ... p.
How many F
Would you say that in your work, you are under:
3
severe nervous strain
2
some nervous strain
1
little or no nervous strain
Could you say what is the main cause of strain?
Generic text
How does it affect you?
Generic text
Please would you write here a brief description of your present job and the responsibilities you have at work.
Long text

SMOKING

Please ring the codes that apply to you showing your past and present smoking habits.

Are you now

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

1 - an ex-smoker of

2 - an occasional smoker of

3 - a regular smoker of

0 - never smoked

cigarettes
cigars
a pipe
How far do/did you usually take the smoke in?
1
hold it in the mouth
2
to the back of the throat
3
partly in to the chest
4
deeply
When did you (last) give up cigarette smoking (for a month or more)?
0
never given it up
Generic date
Over the past year, how many cigarettes a day have you usually smoked? ... cigarettes
How many I
How many cigarettes a day were you smoking before you gave up? ... cigarettes
How many I

HEIGHT AND WEIGHT

How tall are you (without shoes)? ... ft ... ins
How many I
Inches in foot
How much do you weigh (without clothes)? (if pregnant please give your weight before. this pregnancy) ... st ... lbs
How many I
Pounds in stone
How long ago was this weight checked on the scales? within the last ... weeks/month
How many I
1
today
What is your present waist measurement
1
Is this measured by a tape
2
estimated by the waist size of your skirt/trousers

SLEEP

During the last month or so have you been having any trouble with your sleep?
1
Yes
0
No
What sort of trouble have you had? (ring more than one if necessary)
1
I have difficulty in getting off to sleep
2
I wake up in the night and can't get off to sleep again quickly
3
I have unpleasant dreams or nightmares
4
I wake up too early in the morning and stay awake
5
I sleep all night but still feel tired in the morning
*
Any other sort of trouble? (please describe)
Other

COUGH

Do you usually cough first thing in the morning in the winter?
1
Yes
0
No
Do you usually cough during the day or night in winter?
1
Yes
0
No
Do you cough like this on most days for as much as 3 months each winter?
1
Yes
0
No
During the past three years have you had any chest illness ( e.g. bronchitis, pneumonia) which has kept you off work or indoors for a week or more?
1
Yes
0
No

RHEUMATISM AND BACK PAIN

Have you ever had:- Arthritis or rheumatism of your joints? (arms, legs, hands, feet)
1
Yes
0
No
Have you ever had:- Trouble with your back?
1
Yes
0
No
How many times have you had this trouble Arthritis or rheumatism
1
once or twice
2
several times
3
frequently
How many times have you had this trouble Trouble with your back
1
once or twice
2
several times
3
frequently
Which parts have been affected? Arthritis or rheumatism
Generic text
Which parts have been affected? Trouble with your back
Generic text
ls the trouble relieved by exercise? Arthritis or rheumatism
1
Yes
0
No
ls the trouble relieved by exercise? Trouble with your back
1
Yes
0
No
Did this trouble come on after an injury? Arthritis or rheumatism
1
Yes
0
No
Did this trouble come on after an injury? Trouble with your back
1
Yes
0
No
Have you had this trouble during the last 12 months? Arthritis or rheumatism
1
Yes
0
No
Have you had this trouble during the last 12 months? Trouble with your back
1
Yes
0
No
Have you had to stay away from work because of the trouble? Arthritis or rheumatism
1
yes, in the last 12 months
2
yes, earlier than this
0
No
Have you had to stay away from work because of the trouble? Trouble with your back
1
yes, in the last 12 months
2
yes, earlier than this
0
No
Have you seen a doctor about the trouble? Arthritis or rheumatism
1
yes, in the last 12 months
2
yes, earlier than this
0
No
What did he say was wrong? Arthritis or rheumatism
Generic text
Have you seen a doctor about the trouble? Trouble with your back
1
yes, in the last 12 months
2
yes, earlier than this
0
No
What did he say was wrong? Trouble with your back
Generic text
Do you ever get pain in the pit of your stomach? (in the area shown in green in the diagram)
1
Yes
0
No
Have you had this pain during the last 12 months?
1
Yes
0
No
When did you first notice this pain? about ...weeks ago about ... months ago about ... years ago
How many I
Do you get this pain
1
once a year or less
2
several times a year
3
about once each month
4
several times a month
How long does the pain last?
Generic text
Does food ever make it better?
1
Yes
0
No
9
Don't know
Does food ever make it worse?
1
Yes
0
No
9
Don't know
Does the pain ever wake you at night?
1
Yes
0
No
Have you taken any medicine or tablets for this pain?
1
Yes
0
No
What do you/did you take?
Generic text
Do they make the pain better?
2
Yes
1
Sometimes
0
No
Have you had to stay away from work because of the pain?
1
yes, in the last 12 months
2
yes, earlier than this
0
No
Have you consulted a doctor about the pain?
1
yes, in the last 12 months
2
yes, earlier than this
0
No
What did he say was wrong?
Generic text
If he did any special investigations, please tell us what they were:
Generic text

HEADACHE

Have you had a headache during the past 12 months?
1
Yes
0
No
Are your headaches usually
1
fairly mild?
2
quite severe?
3
very severe?
How often do you get a headache?
1
once a year or less
2
several times a year
3
about once a month
4
several times a month
Are your headaches on one side only?
1
never
2
sometimes
3
usually
4
always
Before your get a headache, do you ever know one is coming?
1
Yes
0
No
What do you notice?
Generic text
When you have a headache do you:
1
ever feel sick?
2
ever vomit?
0
no feelings of sickness
Have you ever consulted a doctor about the headache?
1
yes, in the last 12 months
2
yes, earlier than this
0
No
What did he say was wrong?
Generic text

SPORTS AND FITNESS

Do you think of yourself as being
1
very fit
2
fairly fit
3
not very fit

Please ring the codes below, indicating any sports or keep fit activities you take part in, and showing how often you do these things (during the season)

cs_q30_b-c_Y any others: (please describe) cs_dash cs_q30_b-c

1 - Seldom or never

2 - several times a year

3 - At least once a month

4 - At least once a week

swimming 1 -
swimming 2 -
swimming 3 -
cycling 1 -
cycling 2 -
cycling 3 -
squash, tennis or badminton 1 -
squash, tennis or badminton 2 -
squash, tennis or badminton 3 -
keep fit classes 1 -
keep fit classes 2 -
keep fit classes 3 -
Apart from these, is there anything else you do or avoid doing in order to keep fit? Please write here what you do and (if appropriate) how often.
Generic text
ls there any aspect of your health that you worry about, even though you may not have consulted a doctor about it?
1
Yes
0
No
Please describe what worries you and say whether you have ever consulted a doctor about it.
Generic text
Has anything important happened to you in the last five years that we have not asked about? Please write here anything you wish to tell us.
Generic text
When we asked you about your health in 1972 you said you were suffering from ... Please give details of any treatment you received for the condition
Generic text
Are you troubled by it now?
1
Yes
0
No
please give details
Generic text
Does it restrict your activities at home or work in anyway?
1
Yes
0
No
please give details
Generic text
Today's date
Generic date
PLEASE CHECK THAT YOU HAVE ANSWERED ALL THE QUESTIONS
Please post the form directly to us in the special envelope
THANK YOU VERY MUCH FOR ALL YOUR HELP