Family Health History – Male Version
Question Number
Verbatim Question
Response categories and comments
1
What is your birthrate?
Month ____
Year______
1b
What state were you born in?
State __________
enter two letter state code
DC=District of Columbia
I was born outside the U.S.
1 = box checked
2
What is your sex?
1=male
2=female
3a
What is your race?
1=asian
2=black
3=white
4=american indian
5=other
9=multiple boxes checked
3b
Are you of Mexican, Latino, or Hispanic origin?
1=yes
2=no
4
Please check how far you’ve gone in school….
(Choose one)
1=Didn’t go to high school
2=Some high school
3=High school graduate or GED
4=Some college or technical school
5= 4 year college graduate
9=Multiple boxes checked
5
What is your current marital status? Are you now…
1=married
2=not married, but living together
with a partner
3=widowed
4=separated
5=divorced
6=never married
9=multiple answers checked
6a
How many times have you been married?
1=1
2=2
3=3
4=4 or more
5=never married
9=multiple boxes checked
FHH Male