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OMB No.: 0920-0214 Expiration date: 12/31/2026
National Health Interview Survey
Start Here
How many people, including yourself, live or stay
at this address?
Please use a blue or black pen to complete
the paper questionnaire.
INCLUDE...
✓ people who are not related to you
✓ people who are away on travel
✓ babies and small children
✓ people staying here who have no other place where
they usually live or stay
✓ college students living in on-campus housing
Place an X to mark your answers as
shown below:
x
Yes
No
DO NOT INCLUDE anyone living somewhere else,
such as...
When entering numbers, please align the
numbers to the right, as shown below:
✗ a college student living in off-campus housing
✗ someone in the Armed Forces on deployment
➜
Number of people
For help or questions about completing this
form, please call 1-800-618-5888. The
telephone call is free.
Notice – CDC estimates the average public reporting burden for this collection of information as 30 minutes per response, including
the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information
needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not
required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding
this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to
CDC/ATSDR Information Collection Review Office, 1600 Clifton Road, MS H21-8, Atlanta, GA 30333; ATTN: PRA (0920-0214).
Assurance of Confidentiality: We take your privacy very seriously. All information that relates to or describes identifiable
characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and
agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance
with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)), and the Confidential Information Protection and Statistical
Efficiency Act or CIPSEA (44 U.S.C. 3561-3583). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken
an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable
information about you and/or your family. In addition to the above cited laws, NCHS complies with the Federal Cybersecurity
Enhancement Act of 2015 (6 U.S.C. § 151 and 151 note) which protects Federal information systems from cybersecurity risks by
screening their networks.
NHIS-1R (2025)
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A. You and Your Household
A1 Fill out the following information for everyone, including yourself, who is living or staying at this address.
If there are more than 6 people living or staying at this address, start with the OLDEST person, who we
will call “Person 1” and continue with the next oldest until you have completed the section.
Person 1
Last Name (Please print)
First Name
Month
Sex
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
Person 2
Last Name (Please print)
First Name
Month
Sex
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
Person 3
Last Name (Please print)
First Name
Month
Sex
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
Person 4
Last Name (Please print)
First Name
Month
Sex
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
Person 5
Last Name (Please print)
First Name
Month
Sex
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
Person 6
Last Name (Please print)
First Name
Month
Sex
NHIS-1R
Male
Female
MI
Year
Date of birth
Age in years
Print the numbers
in the boxes.
Enter ’0’ for babies
under 1 year old.
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A2 Of the people listed, which adult age 18 or older will have the next birthday?
Write their name here:
A3 Is this you?
Yes ➔ Continue to B. Your Health below.
No ➔ Give this questionnaire to the person named in A2 and ask them to continue to B. Your Health below.
B. Your Health
B1
B5
Would you say your health in general is...
Have you EVER been told by a doctor or other
health professional that you had asthma?
Excellent
a. Do you still have asthma?
Very good
Yes
Good
No
b. During the past 12 months, have you had
an episode of asthma or an asthma
attack?
Fair
Yes
Poor
B2
No ➔ SKIP to question B6
Yes
No
c. During the past 12 months, have you had
to visit an emergency room or urgent
care center because of asthma?
In general, how satisfied are you with your life?
Very satisfied
Yes
No
Satisfied
B6
Dissatisfied
Very dissatisfied
B3
a. Coronary heart disease
Have you EVER been told by a doctor or other
health professional that you had hypertension,
also called high blood pressure? If you take
medication to control your high blood pressure,
please answer yes.
Yes
b. Angina, also called angina pectoris
c. A heart attack, also called
myocardial infarction
No
d. A stroke
During the past 12 months, have you had
hypertension or high blood pressure?
Yes
Have you EVER been told by a doctor or other
health professional that you had any of the
following?
Mark (X) yes or no for each item.
Yes
No
B7
No
Have you EVER been told by a doctor or other
health professional that you had any of the
following?
Mark (X) yes or no for each item.
Yes
B4
a. COPD, emphysema, or chronic
bronchitis
Have you EVER been told by a doctor or other
health professional that you had high
cholesterol? If you take medication to control your
high cholesterol, please answer yes.
Yes
b. Arthritis, rheumatoid arthritis,
gout, lupus, or fibromyalgia
c. Kidney problem, protein in the
urine, or kidney disease
No
During the past 12 months, have you had high
cholesterol?
Yes
d. Hepatitis
e. Cirrhosis or any other kind of
long-term liver condition
No
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B8
C. Your Life Right Now
Have you EVER been told by a doctor or other
health professional that you had cancer or a
malignancy of any kind?
C1
No ➔ SKIP to question B9
Yes
a. What kind of cancer was it?
Mark (X) for all that apply.
How would you rate your quality of life, focusing
on what matters most to you?
Excellent
Very good
Breast
Good
Lung
Fair
Prostate
Poor
Skin (melanoma)
C2
Colorectal
Any other type of cancer – Please specify
C
How would you rate your social and family
connections?
Excellent
Very good
Good
b. How old were you when a doctor or other
health professional first told you that you
had cancer?
Fair
Poor
years old
B9
Has a doctor or other health professional EVER
told you that you have diabetes? Do not include
prediabetes, borderline diabetes, or gestational
diabetes.
Yes
C3
In general, how healthy is your overall diet?
Excellent
Very good
No
Good
How old were you when a doctor or health
professional first told you that you had
diabetes?
Fair
Poor
years old
C4
How would you rate your physical activity,
compared with people in your age group?
B10 How tall are you without shoes? Answer in feet
and inches OR meters and centimeters. Your best
estimate is fine.
Excellent
Very good
feet
AND
inches
Good
OR
Fair
meters
AND
centimeters
Poor
B11 How much do you weigh? Answer in pounds OR
kilograms. Your best estimate is fine.
pounds
OR
kilograms
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C5 How would you rate your ability to manage
C9
stress?
Over the last 2 weeks, how often have you been
bothered by little interest or pleasure in doing
things?
Excellent
Not at all
Very good
Several days
Good
More than half the days
Fair
Nearly every day
Poor
C10 Over the last 2 weeks, how often have you been
bothered by feeling down, depressed, or hopeless?
C6 How would you rate your sleep?
Excellent
Not at all
Very good
Several days
Good
More than half the days
Fair
Nearly every day
Poor
C11 Over the last 2 weeks, how often have you been
bothered by feeling nervous, anxious, or on edge?
C7 How would you rate your ability to find meaning
and purpose in your daily life?
Not at all
Excellent
Several days
Very good
More than half the days
Good
Nearly every day
Fair
C12 Over the last 2 weeks, how often have you been
bothered by not being able to stop or control
worrying?
Poor
C8 How would you rate your ability to manage your
Not at all
health, focusing on aspects of your health that
matter most to you?
Several days
Excellent
More than half the days
Very good
Nearly every day
Good
Fair
Poor
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D. Your Day-to-Day
Experiences
D6
Using your usual language, do you have difficulty
communicating, for example, understanding or
being understood?
No difficulty
D1 Do you have difficulty seeing, even if wearing
glasses or contact lenses?
Some difficulty
No difficulty
A lot of difficulty
Some difficulty
Cannot do at all
A lot of difficulty
D7
Cannot do at all
Because of a physical, mental, or emotional
condition, do you have difficulty doing errands
alone, such as visiting a doctor’s office or
shopping?
D2 Do you have difficulty hearing, even if using a
hearing aid(s)?
No difficulty
No difficulty
Some difficulty
Some difficulty
A lot of difficulty
A lot of difficulty
Cannot do at all
Cannot do at all
D8
D3 Do you have difficulty walking or climbing steps?
No difficulty
No difficulty
Some difficulty
Some difficulty
A lot of difficulty
A lot of difficulty
Cannot do at all
D4 Do you have difficulty remembering or
concentrating?
Because of a physical, mental, or emotional
condition, do you have difficulty participating in
social activities, such as visiting friends, attending
clubs and meetings, or going to parties?
Cannot do at all
D9
No difficulty
Are you limited in the kind OR amount of work you
can do because of a physical, mental, or emotional
problem? Work includes paid work, volunteer work,
schoolwork, and homework.
Some difficulty
Yes
A lot of difficulty
No
Cannot do at all
D10 During the past 12 months, about how many days
of work did you miss because you had an illness,
injury, or disability? Do not include family, maternity,
or paternity leave.
D5 Do you have difficulty with self-care, such as
washing all over or dressing?
No difficulty
days
Some difficulty
A lot of difficulty
Cannot do at all
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E. Your Health Care
Coverage
D11 In the past 3 months, how often did you have
pain?
Never ➔ SKIP to E. Your Health Care Coverage
The next questions are about health insurance.
Some days
Include health insurance obtained through
employment or purchased directly, as well as
government programs like Medicare, Medicaid,
and Children’s Health Insurance Program, that
provide medical care or help pay medical bills.
Most days
Every day
D12 Thinking about the last time you had pain, how
E1
much pain did you have?
Are you now covered by any kind of health
insurance or some other kind of health care plan?
A little
Yes
A lot
No ➔ SKIP to question E4 on page 8.
Somewhere between a little and a lot
E2
D13 Over the past 3 months, how often did pain limit
your life or work activities?
What kind of health insurance or health care
coverage do you have?
Mark (X) yes or no for each item.
Yes
No
a. Private health insurance
Never
b. Medicare (including Medicare
Advantage)
Some days
c. Medicare supplement (Medigap)
Most days
d. Medicaid
Every day
e. Children’s Health Insurance
Program (CHIP)
f. TRICARE or other military health
care (CHAMPUS)
g. VA health care or CHAMPVA
h. Indian Health Service
E3
i.
State-sponsored health plan
j.
Other government program
Was any of the health insurance you marked on
E2 obtained through Healthcare.gov, the Health
Insurance Marketplace, or a state-based health
insurance exchange? Healthcare.gov is a website for
the Affordable Care Act, also known as Obamacare.
Yes
No
What is the name of this plan?
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F. Your Health Care
These next few questions are about types of
health insurance you may have had in the past
12 months.
F1
E4
At any time in the past 12 months, did you have
health insurance through a current or former
employer or union?
Yes
Within the past 12 months
No
E5
At least 1 year ago but less than 2 years ago
At any time in the past 12 months, did you have
health insurance purchased through
Healthcare.gov, the Health Insurance Marketplace,
or a state-based health insurance exchange?
Healthcare.gov is a website for the Affordable Care Act, F2
also known as Obamacare.
Yes
No
E6
E7
About how long has it been since you last saw a
doctor or other health professional about your
health? Do not include appointments by video or
phone. Do not include dental care. Include doctors
seen while a patient in a hospital.
2 years ago or more
Never
About how long has it been since you last saw a
doctor or other health professional for a wellness
visit, physical, or general-purpose check-up? If a
wellness exam was combined with a visit for some
other reason, include this visit. An obstetrician/
gynecologist (OB/GYN) may perform this visit.
Within the past 12 months
At any time in the past 12 months, did you have
Medicaid, Medical Assistance, or the Children’s
Health Insurance Program?
At least 1 year ago but less than 2 years ago
Yes
2 years ago or more
No
Never
During the past 12 months, were you covered by
health insurance for...
All of the year
F3
When was the last time you had your blood
pressure checked by a doctor, nurse, or other
health professional?
Within the past 12 months
months
How many months
Some of the year ➔ did you have
coverage?
At least 1 year ago but less than 2 years ago
None of the year
2 years ago or more
Never
F4
When was the last time you had a blood test for
high blood sugar or diabetes by a doctor, nurse,
or other health professional?
Within the past 12 months
At least 1 year ago but less than 3 years ago
3 years ago or more
Never
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F5
During the past 12 months, how many times
have you gone to a retail health clinic about your
health? Retail health clinics are located in a
pharmacy, grocery store, or supercenter. These clinics
can provide common services, such as certain
vaccinations, as well as testing for or treatment of
minor uncomplicated illnesses.
F10 During the past 12 months, have you had a dental
examination or cleaning? Include examinations or
cleanings from all types of dental care providers, such
as dentists, orthodontists, oral surgeons, dental
hygienists, and all other dental specialists.
Yes
None
1 time
No
F11 During the past 12 months, have you had an eye
exam from an eye specialist, such as an
optometrist, ophthalmologist, or eye doctor?
2 or 3 times
4 or more times
F6
During the past 12 months, how many times
have you gone to an urgent care center about
your health? An urgent care center is located in its
own building or space. These centers can provide
services such as x-rays and stitches.
Yes
No
F12 During the past 12 months, did you receive
counseling or therapy from a mental health
professional, such as a psychiatrist, psychologist,
psychiatric nurse, or clinical social worker?
None
Yes
1 time
No
2 or 3 times
4 or more times
F7
F13 During the past 12 months, have you had a flu
vaccination? There are 2 types of flu vaccinations.
One is a shot and the other is a spray, mist, or drop
in the nose.
During the past 12 months, how many times
have you gone to a hospital emergency room
about your health? This includes emergency room
visits that resulted in a hospital admission.
Yes
No
None
1 time
2 or 3 times
4 or more times
F8
During the past 12 months, how many nights have
you been hospitalized? Do not include an overnight
stay in the emergency room.
None
1 night
2 or 3 nights
4 or more nights
F9
During the past 12 months, have you had an
appointment with a doctor, nurse, or other health
professional by video or by phone?
Yes
No
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These next questions are about different types of
colorectal cancer screening.
F16 Have you ever had a blood stool or FIT test, using
a HOME kit? These are tests to determine whether
you have blood in your stool or bowel movement and
can be done at home using a kit. You use a stick or
brush to obtain a small amount of stool at home and
send it back to the doctor or lab. This may also be
called a fecal occult blood test or fecal
immunochemical test.
F14 Have you ever had a colonoscopy or
sigmoidoscopy exam? These are exams in which a
doctor inserts a tube into the rectum to look for polyps
or cancer.
Yes
No
Yes
About how long has it been since your
MOST RECENT colonoscopy or
sigmoidoscopy?
No
When was your most recent blood stool or
FIT test, using a home test kit?
Within the past 12 months
Within the past 12 months
At least 1 year ago but less than 2 years ago
At least 1 year ago but less than 2 years ago
At least 2 years ago but less than 3 years ago
At least 2 years ago but less than 3 years ago
At least 3 years ago but less than 5 years ago
At least 3 years ago but less than 5 years ago
At least 5 years ago but less than 10 years ago
At least 5 years ago but less than 10 years ago
10 years ago or more
10 years ago or more
F15 Have you ever had a CT colonography or virtual
F17 Have you ever had a Cologuard test? The
Cologuard test is another type of stool test for colon
cancer. It tests for blood in your stool and DNA
changes. With this test, you mail a whole bowel
movement back in a container to be tested.
colonoscopy? CT colonography, sometimes called
virtual colonoscopy, is a test that looks for cancer in
the colon. Unlike regular colonoscopies, you do not
need medication to make you sleepy during the test.
In this test, your colon is filled with air, and you are
moved through a donut-shaped X-ray machine as
you lie on your back and then your stomach.
Yes
No
When was your most recent Cologuard test?
Yes
No
Within the past 12 months
When was your most recent CT colonography
or virtual colonoscopy?
At least 1 year ago but less than 2 years ago
Within the past 12 months
At least 2 years ago but less than 3 years ago
At least 1 year ago but less than 2 years ago
At least 3 years ago but less than 5 years ago
At least 2 years ago but less than 3 years ago
At least 5 years ago but less than 10 years ago
At least 3 years ago but less than 5 years ago
10 years ago or more
At least 5 years ago but less than 10 years ago
10 years ago or more
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H. Your Prescription
Medication
G. Your Health Care Costs
G1 During the past 12 months, have you DELAYED
getting dental care because of the cost?
H1
Yes
At any time in the past 12 months, did you take
prescription medication?
Yes
No
No ➔ SKIP to I. Women’s Health on page 12.
G2 During the past 12 months, was there any time
when you needed dental care, but did NOT get it
because of the cost?
H2
Are you now taking any medication prescribed
by a doctor for high blood pressure?
Yes
Yes
No
No
G3 During the past 12 months, have you DELAYED
getting medical care because of the cost? Do not
include dental care.
H3
Are you now taking any medication prescribed
by a doctor to help lower cholesterol?
Yes
Yes
No
No
H4
G4 During the past 12 months, was there any time
when you needed medical care, but did NOT get
it because of the cost? Do not include dental care.
Are you now taking diabetic pills to lower blood
sugar? These are sometimes called oral agents or oral
hypoglycemic agents.
Yes
Yes
No
No
H5
G5 During the past 12 months, were any of the
following true for you?
Mark (X) yes or no for each item.
Are you now taking insulin? Insulin can be taken by
shot or pump.
Yes
Yes
No
No
a. You skipped medication doses
to save money.
b. You took less medication to save
money.
H6
c. You delayed filling a prescription
to save money.
Yes
G6 During the past 12 months, was there any time
when you needed prescription medication, but
did NOT get it because of the cost?
Yes
Other than insulin, are you now taking any
injectable medication to lower blood sugar or
lose weight? These medications include GLP-1
injectables, such as Ozempic, Wegovy, Saxenda,
Victoza, Trulicity, Mounjaro, and Byetta.
No
H7
No
G7 If you get sick or have an accident, how worried
At any time in the past 12 months, did you take
prescription medication to help you with your
emotions or with your concentration, behavior,
or mental health?
SKIP to question I1
No ➔ on page 12.
Yes
are you that you will be able to pay your medical
bills?
a. Are you now taking prescription
medication for depression?
Very worried
Yes
Somewhat worried
No
b. Are you now taking prescription
medication for anxiety? Anxiety can include
feeling worried, nervous, or anxious.
Not at all worried
Yes
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I. Women’s Health
J. Your Physical Activity
What is your sex?
I1
The next questions are about physical activities
such as exercise, sports, or physically active
hobbies that you may do in your LEISURE time.
These questions are about 2 different types of
physical activity — moderate-intensity and
vigorous-intensity.
Male ➔ SKIP to J. Your Physical Activity
Female
Have you EVER HAD a mammogram? A
mammogram is an x-ray taken only of the breast by a
machine that presses against the breast.
I2
Yes
J1
No
About how long has it been since your MOST
RECENT mammogram?
How often do you do MODERATE-INTENSITY
leisure-time physical activities? Moderate-intensity
activities cause moderate increases in breathing or
heart rate.
times per day
OR
Within the past 12 months
times per week
At least 1 year ago but less than 2 years ago
OR
At least 2 years ago but less than 3 years ago
At least 3 years ago but less than 5 years ago
times per month
OR
At least 5 years ago but less than 10 years ago
Never ➔ SKIP to J3
10 years ago or more
OR
There are 2 different kinds of tests to check for
cervical cancer. One is a Pap smear or Pap test
and the other is the HPV or Human Papillomavirus
test. Have you EVER HAD a test or tests to check
for cervical cancer? These are routine tests for
women in which a doctor or other health professional
takes a sample from the cervix through the vagina with
a swab or brush and sends it to the lab.
I3
Yes
I am unable to do this
type of activity ➔ SKIP to J3
J2
About how long do you do these moderate
leisure-time physical activities each time?
minutes each time
No
OR
When did you have your MOST RECENT
test to check for cervical cancer?
Within the past 12 months
hours each time
J3
At least 1 year ago but less than 2 years ago
How often do you do VIGOROUS-INTENSITY
leisure-time physical activities? Vigorous-intensity
activities cause large increases in breathing or heart rate.
At least 2 years ago but less than 3 years ago
times per day
At least 3 years ago but less than 5 years ago
OR
At least 5 years ago but less than 10 years ago
times per week
10 years ago or more
OR
I4
Have you had a hysterectomy? A hysterectomy is
when the uterus or womb is removed. This is different
from having your tubes tied.
times per month
OR
Yes
Never ➔ SKIP to J5 on page 13.
No
OR
I am unable to do this
type of activity ➔ SKIP to J5 on page 13.
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J4
K. Nicotine and Alcohol
Use
About how long do you do these vigorous
leisure-time physical activities each time?
minutes each time
K1
OR
Yes
hours each time
J5
Have you smoked at least 100 cigarettes in your
ENTIRE LIFE?
No
Do you now smoke cigarettes every day,
some days, or not at all?
How often do you do leisure-time physical
activities specifically designed to STRENGTHEN
your muscles such as sit-ups, push-ups, or lifting
weights? Include any muscle-strengthening activities
you may have reported earlier as moderate-intensity
or vigorous-intensity leisure-time physical activities.
Every day
Some days
Not at all
times per day
K2
OR
times per week
Have you ever used an e-cigarette or other
electronic vaping product, even just one time, in
your entire life? Include e-cigarettes used for nicotine.
Do not include marijuana use.
Yes
OR
No
Do you now use e-cigarettes or other
electronic vaping products every day,
some days, or not at all?
times per month
OR
Every day
Never
Some days
OR
Not at all
I am unable to do this type of activity
J6
In the past 7 days, did you walk for
transportation? This is walking you might have done
to travel to and from work, to do errands, or to go
from place to place.
Yes
K3
No
Yes
Did you generally walk for at least 10
minutes at a time?
Yes
J7
In your ENTIRE LIFE, have you had at least 1 drink
of any kind of alcohol, not counting small tastes or
sips? Alcohol includes beer, wine, wine coolers, liquors
such as vodka, whiskey or rum, mixed drinks or cocktails
with alcohol, and any other type of alcoholic drink.
No
During the past 12 months, did you ever have
4 or more drinks in a day?
No
Yes
No
Sometimes you may walk for fun, relaxation,
exercise, or to walk the dog. In the past 7 days,
did you walk for any of these reasons? Do not
include walking for transportation.
Yes
No
Did you generally walk for at least 10
minutes at a time?
Yes
J8
No
On average, how many hours of sleep do you get
in a 24-hour period? Enter whole numbers only.
hours
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L. You and Your Family
L1
L4
Do you consider yourself to be Hispanic or Latino?
Never served in the military
Yes
Only on active duty for training in the
Reserves or National Guard
No
L2
Now on active duty
What race or races do you consider yourself to be?
Mark (X) for all that apply.
On active duty in the past, but not now
White
L5
Black or African American
Is the place where you usually live owned or
rented by you or someone in your family?
American Indian
Owned or being bought
Alaska Native
Rented
Native Hawaiian
Other arrangement
Other Pacific Islander
L3
Did you ever serve on active duty in the U.S.
Armed Forces, military Reserves, or National
Guard?
L6
Are you now living with a spouse or partner?
Asian
Yes
Some other race
No
What is the HIGHEST level of school you have
completed or the highest degree you have
received?
L7
What is your current legal marital status?
Married
Less than a high school diploma
Widowed
Regular high school diploma
Divorced
GED or equivalent
Separated
Some college, no degree
Never married
Occupational, technical, or vocational program
L8
Do you think of yourself as...
Two year or Associate’s degree
Lesbian or gay
Bachelor’s degree (Example: BA, AB, BS, BBA)
Straight, that is, not lesbian or gay
Master’s degree (Example: MA, MS, MEng,
MEd, MBA)
Bisexual
Something else
Professional school degree (Example: MD, DDS,
DVM, JD)
I don’t know the answer
Doctoral degree (Example: PhD, EdD)
L9
Were you born in the United States or a
U.S. territory?
Yes, born in a state or the District of Columbia
Yes, born in a U.S. territory
No
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34015024
L10 Which of the following best describes your
L13 What is your best estimate of the total income of
current employment status? Mark 1 box.
all family members from all sources in 2024?
Report amount before taxes. Report net income after
business expenses if self-employed.
Employed full-time
Employed part-time
$
.00
Working WITHOUT pay at a family-owned business
Not employed but looking for work
L14 What is your age today?
Age in years
Not employed and not looking for work
Retired
L11 Not including yourself, how many of the people in
your household are members of your family? For
this survey, family refers to everybody living together
who are related by birth, marriage, or adoption, as well
as any unrelated children who are cared for by the
family, such as foster children. Family also includes any
people living together as a couple and their children.
If you live alone or live only with unrelated roommates,
please answer zero (00).
Number of family members in household
The next questions are about your total family
income in 2024.
L12 In 2024, did you or any family member 18 or older
receive income from any of the following sources?
Mark (X) yes or no for each item.
Yes
No
a. Wages, salaries, commissions,
bonuses, tips, or self-employment
b. Interest-bearing accounts or
investments
c. Dividends from stocks or mutual
funds
d. Net rental income, royalty income,
or income from estates and trusts
e. Social Security or Railroad
Retirement
f. Supplemental Security Income (SSI)
g. Any public assistance or welfare
payments from the state or local
welfare office
h. Retirement income, pensions,
survivors or disability income
i.
Any other sources of income
received regularly such as Veterans’
VA payments, unemployment
compensation, child support, or
alimony
NHIS-1R
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34015016
Mailing Instructions
➜
Please print today’s date. This should be the date this form was completed.
Month
Day
Year
On behalf of the U.S. Department of Health and Human Services, we would like to thank you
for the time and effort you have spent sharing information about you and your family.
Your answers to this survey will provide better information for health policies and decisions
that affect millions of people across the United States.
Place the completed questionnaire in the postage-paid return envelope. If the
envelope has been misplaced, please mail the questionnaire to:
DIRECTOR
U.S. Census Bureau
P.O. Box 5000
Jeffersonville, IN 47199-5000
NHIS-1R
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| File Type | application/pdf |
| Author | OneFormUser |
| File Modified | 2025-08-28 |
| File Created | 2025-08-28 |