Getting started
Why are we conducting this survey?
Statistics Canada is conducting a survey about the health and well-being of Canadians. The Canadian Community Health Survey asks people from all provinces and territories about their health status, factors that affect their health and their use of health care services.
One of the main goals of the survey is to gather information to help improve health programs and services provided in your region.
Your information may also be used by Statistics Canada for other statistical and research purposes.
Although voluntary, your participation is important so that the information collected is as accurate and complete as possible.
Other important information
Authorization and confidentiality
Data are collected under the authority of the Statistics Act, Revised Statutes of Canada, 1985, Chapter S-19. Your information will be kept strictly confidential.
Record linkages
To enhance the data from this survey and to reduce the response burden, Statistics Canada will combine the information you provide with information from the tax data of all members of your household. Statistics Canada and your provincial or territorial ministry of health, or the Institut de la statistique du Québec for Quebec respondents, may also combine the information you provide with other surveys or administrative sources.
Statistics Canada may also combine the information you provide with other survey or administrative data sources.
Contact us if you have any questions or concerns about record linkage:
Email: Infostats
Telephone: 1-877-949-9492
Mail: Chief Statistician of Canada
Statistics Canada
Attention of Director, Centre for Population Health Data
150 Tunney's Pasture Driveway
Ottawa, Ontario K1A 0T6
Date of birth
What is [FirstName's/your] date of birth?
- Year
- (dropdown list of years from 1906 to 2008)
- Month
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
- Day
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
Sex and gender
The following questions are about sex at birth and gender.
What was [FirstName's/your] sex at birth?
Sex refers to sex assigned at birth.
What is [FirstName's/your] gender?
Gender refers to current gender which may be different from sex assigned at birth and may be different from what is indicated on legal documents.
Is it:
- Male
- Female
- Or please specify
- Specify [FirstName's/your] gender
Marital status
What is [your/FirstName's] marital status?
Is it:
- Married
For Quebec residents only, select the "Married" category if your marital status is "civil union"
- Living common law
- Two people who live together as a couple but who are not legally married to each other.
- Never married (not living common law)
- Separated (not living common law)
- Divorced (not living common law)
- Widowed (not living common law)
Family relationships
What is the relationship of the following [people/person] to [you/FirstName] [BLANK/, age [AGE]]
- Husband or wife
- Common-law partner
- Father or mother
- Son or daughter
- Brother or sister
- In-law
- Other related
Select the type of relationship
- Aunt or uncle
- Cousin
- Niece or nephew
- Grandfather or grandmother
- Grandson or granddaughter
- Other relative
- Unrelated
- Specify the relationship to this person
Main activity
In the past 12 months, did [you/FirstName] work at a job or business?
Regardless of the number of hours.
In the past 12 months, was working at a job or business [your/FirstName's] main activity?
During the past 12 months, what was [your/FirstName's] main activity?
If the main activity was "sickness" or "short-term illness", indicate the usual main activity.
Was it:
- Looking for paid work
- Going to school
- Caring for [your/his/her] children
- Household work
- Retired
- Maternity, paternity or parental leave
- Long-term illness
- Volunteering or care-giving other than for [your/his/her] children
- Other
- Specify the main activity
School attendance
[Are you] [Is FirstName] currently attending school, such as high school, college, CEGEP or university?
Report only attendance for courses that can be used as credits towards a certificate, diploma or degree. Distance learning for credit is included.
[Are you] [Is FirstName] enrolled as a full-time or part-time student?
Each educational institution classifies students as full-time or part-time depending on the type of program, and the number of courses, credits or hours of instruction.
- Full-time student
- Part-time student
General health
The following question is about health. By health, we mean not only the absence of disease or injury but also physical, mental and social well-being.
In general, how is [your/FirstName's] health?
Would you say:
- Excellent
- Very good
- Good
- Fair
- Poor
In general, how is your mental health?
Would you say:
- Excellent
- Very good
- Good
- Fair
- Poor
Thinking about the amount of stress in [your/his/her] life, how would you describe most of [your/his/her] days?
Would you say:
- Not at all stressful
- Not very stressful
- A bit stressful
- Quite a bit stressful
- Extremely stressful
The next question is about your main job or business in the past 12 months.
How would you describe most days at work?
Would you say:
- Not at all stressful
- Not very stressful
- A bit stressful
- Quite a bit stressful
- Extremely stressful
How would you describe your sense of belonging to your local community?
Would you say:
- Very strong
- Somewhat strong
- Somewhat weak
- Very weak
Life satisfaction measures
Using a scale of 0 to 10, where 0 means "Very dissatisfied" and 10 means "Very satisfied", how do you feel about your life as a whole right now?
- 0 – Very dissatisfied
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 – Very satisfied
Sense of meaning and purpose
Using a scale of 0 to 10, where 0 means "Not at all" and 10 means "Completely", to what extent do you feel the things you do in your life are worthwhile?
Would you say:
- 0 – Not at all
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10 – Completely
Future outlook
Thinking about your life in general, how often would you say you have a hopeful view of the future?
Would you say:
- Always
- Often
- Sometimes
- Rarely
- Never
Mental health
The following questions deal with feelings you may have had during the past month.
During the past month, how often did you feel the following?
a. Nervous
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
b. Hopeless
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
c. Restless or fidgety
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
d. So depressed that nothing could cheer you up
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
e. That everything was an effort
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
f. Worthless
- All of the time
- Most of the time
- Some of the time
- A little of the time
- None of the time
Pregnancy
To better understand [your/her] health information, it is important to know if [you are] [FirstName is] pregnant.
[Are you] [Is she] pregnant?
Height and weight
How tall [are/is] [you/FirstName] without shoes on?
Report the height to the nearest inch or centimetre.
OR
How much [do you] [does FirstName] weigh?
Report the weight to the nearest pound or kilogram.
- Weight
- Pounds or kilograms
- Pounds
- Kilograms
Multiple chemical sensitivities
Now a few questions about multiple chemical sensitivities (MCS).
MCS is a chronic condition where people experience symptoms from exposure to low levels of multiple unrelated chemicals (such as perfume, scented products, or smoke) at levels that do not cause symptoms in the unaffected population.
Symptoms from exposure include, among others, fatigue, brain fog, asthma, blocked or runny nose, migraines, muscle or joint pain, and itching, burning, watering, or sore eyes.
[Do/Does][you/FirstName] have multiple chemical sensitivities (MCS)?
Was this diagnosed by a health professional?
How old [were/was] [you/he/she] when the first symptoms appeared?
How old [were/was] [you/he/she] when this was first diagnosed?
Chronic pain
Now a few questions about chronic pain. Chronic pain is defined as pain that persists or recurs for more than three months.
[Do you] [Does FirstName] live with chronic pain?
Include any pain that has persisted or has been recurring for at least three months, such as pain resulting from chronic migraine, cancer, arthritis, a surgery or injury, or another underlying disease or issue; or pain that has persisted or has been recurring for at least three months with no identifying causes.
Was this chronic pain diagnosed by a health professional?
Chronic conditions
The next question is about long-term health conditions. These are conditions which are expected to last or have already lasted 6 months or more and that have been diagnosed by a health professional.
[Have you] [Has FirstName] been diagnosed by a health professional with any of the following long-term health conditions?
Include only conditions [you are] [FirstName is] currently experiencing that have lasted or are expected to last six months or more.
Select all that apply.
[Do you] [Does FirstName] have:
- Cancer
- Chronic blood disorder
e.g., sickle cell anemia, hemophilia
- Diabetes
Include type 1, type 2, gestational or other types of diabetes. Select even if controlled by medication.
Exclude prediabetes.
- High blood cholesterol
Select even if controlled by medication.
- High blood pressure
Select even if controlled by medication.
- Heart disease
e.g., angina, heart failure
- Dementia
e.g., Alzheimer's disease, vascular dementia
- Effects of a stroke
- Neurological disorder
e.g., amyotrophic lateral sclerosis (ALS) or Lou Gehrig's disease, multiple sclerosis (MS), Parkinson's disease, migraine
- Fibromyalgia
- Chronic fatigue syndrome (CFS)
Include myalgic encephalomyelitis.
- Eye disease
e.g., glaucoma, cataracts, macular degeneration, retinopathy, blindness, strabismus
- Ear disease
e.g., hearing impairment, vestibulopathy
- Asthma
- Chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD)
- Sleep apnea
- Bowel disorder
e.g., Crohn's disease, inflammatory bowel disease (IBD)
- Liver disease
e.g., chronic hepatitis
- Osteoporosis
- Arthritis
e.g., osteoarthritis or arthrosis, rheumatoid arthritis, gout, pseudogout
- Back problems
e.g., scoliosis, kyphosis, degenerative disk disease
- Chronic kidney disease
- Exclude kidney stones or infection.
- Dermatological conditions
e.g., eczema, psoriasis
- Celiac disease
- Other
- Specify the type of condition
OR
[Have you] [Has FirstName] ever been told by a doctor or other health professional that [you/he/she] [have/has] prediabetes or that [your/his/her] blood sugar is higher than normal but not high enough to be called diabetes or sugar diabetes?
How old [were/was] [you/FirstName] when [you/he/she] [were/was] first diagnosed with diabetes?
[Were/Was] [you/FirstName] pregnant when [you/she] [were/was] first diagnosed with diabetes?
Exclude prediabetes.
Other than during pregnancy, has a health professional ever told [you/her] that [you/she] [have/has] diabetes?
Exclude prediabetes.
What type of diabetes [were you] [was FirstName] diagnosed with?
Exclude prediabetes or diabetes that develops during pregnancy (gestational diabetes).
If [you/he/she] [do/does] not remember or [were/was] not told, please select "Don't know".
Would you say:
- Type 1 diabetes
- Type 2 diabetes
- Other types of diabetes
- Don't know
When [you were] [FirstName was] first diagnosed with diabetes, how long was it before [you/he/she] [were/was] started on insulin?
Was it:
- Less than 1 month
- 1 month to less than 2 months
- 2 months to less than 6 months
- 6 months to less than 1 year
- 1 year or more
- Never
[Do you] [Does FirstName] currently take insulin for [your/his/her] diabetes?
In the past month, did [you/FirstName] take pills to control [your/his/her] blood sugar?
How old [were/was] [you/FirstName] when [you/he/she] [were/was] first diagnosed with cancer?
[Have you] [Has FirstName] received treatment for cancer in the past 12 months?
What type of cancer [were/was] [you/FirstName] diagnosed with?
Select all that apply.
Was it:
- Breast
- [Prostate]
- Colorectal
- Skin – Melanoma
- Skin – Non-melanoma
- [Ovarian]
- [Cervical]
- [Uterine]
- Lung
- Other
- Specify other type of cancer
How old [were/was] [you/FirstName] when [you/he/she] [were/was] first diagnosed with heart disease?
In the past month, [Have you] [Has FirstName] taken any medicine for high blood pressure?
How old [were/was] [you/FirstName] when the first symptoms of fibromyalgia appeared?
How old [were/was] [you/he/she] when this was first diagnosed?
How old [were/was] [you/FirstName] when the first symptoms of chronic fatigue syndrome (CFS) appeared?
How old [were/was] [you/he/she] when this was first diagnosed?
Chronic mental health and neurodevelopmental conditions
The next question is about long-term mental health conditions, like depression, and neurodevelopmental conditions, like autism. These are conditions which are expected to last or have already lasted 6 months or more and that have been diagnosed by a health professional.
[Have you] [Has FirstName] been diagnosed by a health professional with any of the following long-term mental health or neurodevelopmental conditions?
Include only conditions [you/FirstName] [are/is] currently experiencing that have lasted or are expected to last six months or more.
Select all that apply.
[Do you] [Does FirstName] have:
- A mood disorder
e.g., depression, bipolar disorder, mania or dysthymia
- An anxiety disorder
e.g., phobia, panic disorder or generalized anxiety disorder
- Obsessive-compulsive disorder (OCD)
- A personality disorder
e.g., borderline personality disorder, antisocial personality disorder
- Schizophrenia or any other psychosis
- Post-traumatic stress disorder (PTSD)
- An eating disorder
e.g., anorexia, bulimia, or binge eating disorder
- Attention deficit disorder (ADD) or attention deficit hyperactivity disorder (ADHD)
- Autism, also known as autism spectrum disorder, autistic disorder, Asperger's disorder or pervasive developmental disorder
- Gambling disorder
- A substance use disorder
e.g., alcohol use disorder, cannabis dependence, opioid dependence
- Other
- Specify the type of condition
OR
What type of eating disorder [were/was] [you/FirstName] diagnosed with?
Select all that apply.
Was it:
- Anorexia
- Bulimia
- Binge eating disorder
- Other
- Specify the type of eating disorder
Abilities
The next set of questions asks about [your/FirstName's] ability to do different activities.
[Do/Does] [you/he/she] have difficulty doing any of these activities?
a. Difficulty seeing, even if wearing glasses
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
b. Difficulty hearing, even if using a hearing aid
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
c. Difficulty walking or climbing steps
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
d. Difficulty remembering or concentrating
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
e. Difficulty with self-care
e.g., washing all over or dressing
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
f. Difficulty communicating when using [your/his/her] usual language
e.g., understanding or being understood
- No difficulty
- Some difficulty
- A lot of difficulty
- Cannot do at all or unable to do
Long-term conditions
Do you identify as a person with a disability?
Moderate physical activity
The following questions are about two different types of physical activity.
In the past 7 days, did [you/FirstName] use active transportation like walking or cycling to get to places?
Exclude walking, cycling or other activities done purely for leisure. These activities will be asked about later.
Include using active transportation to go to work, school, bus stops, shopping centres or to visit friends.
In the past 7 days, how much time in total did [you/he/she] spend using active transportation to get to places?
- Hours per week
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- Minutes per week
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
[Not including activities you just reported, in/In] the past 7 days, did [you/FirstName] do sports, fitness or recreational physical activities?
Include organized or non-organized activities. e.g., home or gym exercise, cycling, running, skiing, team sports, walking for exercise or fitness.
Did any of these physical activities make [you/him/her] sweat at least a little and breathe harder?
[Not including activities you just reported, in/In] the past 7 days, how much time in total did [you/FirstName] spend doing sports, fitness or recreational physical activities that made [you/him/her] sweat at least a little and breathe harder?
- Hours per week
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- Minutes per week
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
Sedentary behaviours
The next questions are about the time [you/FirstName] spent sitting or lying down in the last 7 days.
On a school or work day, how much of [your/his/her] free time did [you/he/she] spend watching television or a screen on any electronic device while sitting or lying down?
Include mobile devices, computers, tablets, video game consoles or TV.
- 2 hours or less per day
- More than 2 hours but less than 4 hours
- 4 hours to less than 6 hours
- 6 hours to less than 8 hours
- 8 hours or more per day
- Was not at work or school
[On a day that was not a school or work day, how/How] much of [your/his/her] free time did [you/he/she] spend watching television or a screen on any electronic device while sitting or lying down?
Include mobile devices, computers, tablets, video game consoles or TV.
- 2 hours or less per day
- More than 2 hours but less than 4 hours
- 4 hours to less than 6 hours
- 6 hours to less than 8 hours
- 8 hours or more per day
Activities of daily living
These questions may not apply to [you/FirstName], but we need to ask the same questions of everyone.
Because of any health problem, physical or mental condition, [do/does] [you/he/she] have any difficulty with the following common daily activities?
a. Preparing meals
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
b. Running errands
e.g., shopping for groceries
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
c. Everyday housework
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
d. Personal care
e.g., bathing, dressing, eating or taking medication
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
e. Moving inside the house
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
f. Personal finances
e.g., making transactions or paying bills
- No difficulty
- Some difficulty, but no help required
- Some difficulty and help from others is required
- Cannot do at all
Canada's Food Guide use
Have you ever seen or heard of Canada's Food Guide?
Have you ever used information from Canada's Food Guide?
What did you use the information for?
Please consider everyone in your household when selecting your responses.
Select all that apply
Would you say:
- To choose foods
- To determine how much to eat every day
- To plan meals or to help with grocery shopping
- To assess how well you are eating
- Other
Eating habits
The next questions are about some of [your/FirstName's] eating and drinking habits.
In the past 30 days, how many times did [you/he/she] eat food from a restaurant?
Include fast-food, take-out, sit-down restaurants or prepared food from grocery stores.
Frequency can be reported per month, per week or per day.
In the past 30 days, how many times did [you/he/she] drink the following beverages?
Frequency can be reported per month, per week or per day.
a. 100% pure fruit juice
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
b. Fruit flavoured drinks or sports drinks
e.g., Fruité™ fruit punch, Gatorade™
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
c. Regular soft drinks
Exclude diet soft drinks.
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
d. Sweetened coffee drinks or iced tea
e.g., Starbucks™ Macchiato, Tim Hortons Iced Capp™, Nestea™
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
e. Energy drinks
e.g., Red Bull™, Monster™
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
f. Chocolate milk
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
In the past 30 days, how many times did [you/he/she] eat the following fruits and vegetables?
Include fresh, frozen, canned or dried.
a. Fruits
Exclude fruit juices.
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
b. Dark green vegetables
e.g., broccoli, green beans, dark lettuce, spinach
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
c. Orange-coloured vegetables
e.g., carrots, orange bell peppers, sweet potatoes
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
d. Starchy vegetables
e.g., white potatoes, corn
Exclude deep fried potatoes.
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
e. Other vegetables
e.g., cucumber, celery, cabbage, tomatoes, cauliflower
- Number of times
- Per month, per week or per day
- Per month
- Per week
- Per day
Sleep quality
The next questions are about [your/FirstName's] sleep.
First, we want to know details about [your/his/her] sleep in the past 7 days.
a. On weekdays, at what time did [you/he/she] usually fall asleep?
Midnight is 12 a.m.
- Hour
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- a.m. or p.m.
b. On weekdays, at what time did [you/he/she] usually wake up?
- Hour
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- a.m. or p.m.
c. On weekend days, at what time did [you/he/she] usually fall asleep?
Midnight is 12 a.m.
- Hour
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- a.m. or p.m.
d. On weekend days, at what time did [you/he/she] usually wake up?
- Hour
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- Minutes
- 0
- 5
- 10
- 15
- 20
- 25
- 30
- 35
- 40
- 45
- 50
- 55
- a.m. or p.m.
Overall, how would you rate [your/his/her] sleep quality over the past 7 days?
Would you say:
In the past 7 days, on how many days did [you/he/she] wake up 3 or more times during [your/his/her] sleep?
Number of days
Injury and poisoning
The next questions are about injuries or poisonings which occurred in the past 12 months and were serious enough to limit [your/FirstName's] normal activities whether at home, at work or at leisure, after the injury or poisoning occurred.
In the past 12 months, did [you/FirstName] have any injuries or poisonings?
Exclude repetitive strain injuries and chronic back pain.
Exclude food poisoning, poison ivy, allergies and skin inflammations caused by an allergic reaction.
In the past 12 months, how many times did [you/FirstName] experience injuries or poisonings?
Exclude repetitive strain injuries and chronic back pain.
Exclude food poisoning, poison ivy, allergies and skin inflammations caused by an allergic reaction.
Number of times
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
In the past 12 months, what types of injuries or poisonings did [you/FirstName] have?
Exclude repetitive strain injuries and chronic back pain.
Exclude food poisoning, poison ivy, allergies and skin inflammations caused by an allergic reaction.
Select all that apply.
Was it:
- Head injury
Include concussions and other traumatic brain injuries, skull or facial fracture.
Exclude superficial head injuries such as a cut or scrape.
- Broken or fractured bones
Exclude skull or facial fracture.
- Burn, scald or chemical burn
- Dislocation
- Sprain or strain
e.g., torn ligaments or muscles, back strain
- Cut, puncture, animal or human bite
- Scrape, bruise or blister
- Poisoning
e.g., poisoning by pharmaceuticals, illicit drugs, and chemicals, including pesticides, heavy metals, gases or vapors, and common household substances, such as bleach and ammonia
- Injury to internal organs
- Other
- Specify the type of injury or poisoning
In the past 12 months, how many times did [you/FirstName] have head injuries?
Include concussions and other traumatic brain injuries, skull or facial fracture.
Exclude superficial head injuries such as a cut or scrape.
Number of times
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
The next questions refer to the most serious head injury that occurred in the past 12 months.
What [were/was] [you/FirstName] doing when [your/his/her] most serious head injury occurred?
Include concussions and other traumatic brain injuries, skull or facial fracture.
Exclude superficial head injuries such as a cut or scrape.
[Were you][Was FirstName]:
- Riding a bike
- Riding or driving a motor vehicle
Include off-road vehicles.
- Doing sports or recreational activity
Exclude riding a bike, riding or driving a motor vehicle.
- Doing household chores, outdoor yard maintenance or unpaid work
- Working at a paid job or business
Exclude when driving is [your/his/her] job, and [you/he/she] [were/was] injured while driving.
- Walking
- Going up or down stairs
- Being assaulted or victimized
- Other
Did [you/FirstName] consult a health professional for this head injury?
Include concussions and other traumatic brain injuries, skull or facial fractures.
Exclude superficial head injuries such as a cut or scrape.
When did [you/FirstName] initially consult the health professional?
Was it:
- The same day
- The next day
- 2 to 3 days after the injury
- 4 to 6 days after the injury
- A week or more after the injury
Where did [you/FirstName] initially consult the health professional?
Was it:
- Where the injury happened or on-site medical or paramedical care
e.g., school, university, workplace, residence
Exclude first aid offered by non-health professionals such as colleagues, parents, teachers.
- Hospital emergency room
- Hospital outpatient clinic
e.g., day surgery, treatment services, diagnostic tests
- Doctor's office or clinic
e.g., family doctor or general practitioner's office, walk-in clinic, sports medicine clinic
- Other health care provider's office
e.g., chiropractor, physiotherapist, occupational therapist
- Community health centre [or CLSC]
Include nursing stations.
- Home care
- Virtual care including telephone health lines
e.g., Health Links, Health 811
- Other
- Specify the location of the initial consultation
[Have you] [Has FirstName] received follow-up care from any health professional for this head injury?
Include ongoing care.
Where [are/is] [you/FirstName] currently receiving, or where [have you] [has he/she] received follow-up care from a health professional for this head injury?
Select all that apply.
Was it:
- Hospital emergency room
- Hospital outpatient clinic
e.g., day surgery, treatment services, diagnostic tests
- Doctor's office or clinic
e.g., family doctor or general practitioner's office, walk-in clinic, sports medicine clinic
- Other healthcare provider's office
e.g., chiropractor, physiotherapist, occupational therapist
- Community health centre [or CLSC]
Include nursing stations.
- Rehabilitation centre
- Home care
- Virtual care including telephone health lines
e.g., Health Links, Health 811
- Other
Now some questions about falls that [you/FirstName] may have experienced in the past 12 months.
In the past 12 months, did [you/FirstName] have any falls?
Include events where [you/FirstName] came into contact with the floor or other lower surface, such as falling from heights, losing balance, stumbling, mis-stepping or collapsing.
Select "Yes" even if [you/FirstName ] did not sustain an injury from the fall, and [your/his/her] normal activities, whether at home, at work or at leisure, were not limited.
In the past 12 months, how many times [have you/ has FirstName] fallen?
Would you say:
- Once
- Twice
- Three times or more
In the past 12 months, what have been [your/FirstName's] injuries due to a fall?
Select all that apply.
Was it:
- Sprain or strain
- Bruise
- Cut
- Hip fracture
- Leg or ankle fracture
- Arm or wrist fracture
- Spinal fracture
- Head injury
Include concussions and other traumatic brain injuries, skull or facial fracture.
Exclude superficial head injuries such as a cut or scrape.
- Other
OR
In the past 12 months, which injury was the most serious among the injuries [you/FirstName] had due to a fall?
The most serious injury was the one that imposed the greatest restriction on normal activities.
Was it:
- Sprain or strain
- Bruise
- Cut
- Hip fracture
- Leg or ankle fracture
- Arm or wrist fracture
- Spinal fracture
- Head injury
Include concussions and other traumatic brain injuries, skull or facial fracture.
Exclude superficial head injuries such as a cut or scratch.
- Other
[The next questions refer to the fall where [you/FirstName] had [your/his/her] most serious injury within the past 12 months.]
[The next questions refer to [your/FirstName's] last fall within the past 12 months.]
When did this fall happen?
Was it:
- Winter
- Spring
- Summer
- Fall
Which option best describes how this fall happened?
Was it:
- Slipped, tripped or stumbled while walking on ice or snow
- Slipped, tripped or stumbled while walking on any surface other than ice or snow
- While doing a sport or physical exercise
Exclude walking.
- While going up or down stairs or steps
- While reaching for something
- While rising from furniture
e.g., bed, chair
- While stepping in or out of the bathtub or standing in bathtub
- From elevated position
e.g., ladder, tree, roof
- Due to health problems
e.g., fainting, weakness, dizziness, hip or knee gave out, seizure
- Other
- Specify how this fall happened
Where did this fall happen?
Was it:
- Inside [your/FirstName's] home
- Outside [your/FirstName's] home, but inside a building, facility or worksite
- Outdoors
[Were you] [Was FirstName] using an assistive device at the time of this fall?
e.g., walker, wheelchair, cane, leg brace or grab bar
Did [you/FirstName] consult a health professional for the injury resulting from this fall?
Where did [you/FirstName] initially consult the health professional?
Was it:
- Where the injury happened or on-site medical or paramedical care
e.g., school, university, workplace, residence
Exclude first aid offered by non-health professionals such as colleagues, parents, teachers
- Hospital emergency room
- Hospital outpatient clinic
e.g., day surgery, treatment services, diagnostic tests
- Doctor's office or clinic
e.g., family doctor or general practitioner's office, walk-in clinic, sports medicine clinic
- Other health care provider's office
e.g., chiropractor, physiotherapist, occupational therapist
- Community health centre [or CLSC]
Include nursing stations.
- Home care
- Virtual care including telephone health lines
e.g., Health Links, Health 811
- Other
- Specify the location of the initial consultation
[Have you] [Has FirstName] received follow-up care from any health professional for the injury resulting from this fall?
Include ongoing care.
Where [are/is] [you/FirstName] currently receiving, or where [have you] [has he/she] received follow-up care from a health professional for the injury resulting from this fall?
Select all that apply.
Was it:
- Hospital emergency room
- Hospital outpatient clinic
e.g., day surgery, treatment services, diagnostic tests
- Doctor's office or clinic
e.g., family doctor or general practitioner's office, walk-in clinic, sports medicine clinic
- Other healthcare provider's office
e.g., chiropractor, physiotherapist, occupational therapist
- Community health centre [or CLSC]
Include nursing stations.
- Rehabilitation centre
- Home care
- Virtual care including telephone health lines
e.g., Health Links, Health 811
- Other
Are you worried or concerned that in the future you might fall?
As a result of this concern, have you discontinued any activities you used to do or enjoyed?
Use of protective equipment
In the past 12 months, have you participated in any of these activities?
Select all that apply.
Was it:
- Bicycling
- In-line skating or rollerblading
- Downhill skiing
- Snowboarding
- Skateboarding
- Playing ice hockey
OR
When riding a bicycle, how often do you wear a helmet?
Would you say:
- Always
- Most of the time
- Rarely
- Never
When in-line skating or rollerblading, how often do you wear the following equipment?
a. A helmet
- Always
- Most of the time
- Rarely
- Never
b. Wrist guards or wrist protectors
- Always
- Most of the time
- Rarely
- Never
c. Elbow pads
- Always
- Most of the time
- Rarely
- Never
d. Knee pads
- Always
- Most of the time
- Rarely
- Never
When downhill skiing, how often do you wear a helmet?
Would you say:
- Always
- Most of the time
- Rarely
- Never
When snowboarding, how often do you wear the following equipment?
a. A helmet
- Always
- Most of the time
- Rarely
- Never
b. Wrist guards or wrist protectors
- Always
- Most of the time
- Rarely
- Never
When skateboarding, how often do you wear the following equipment?
a. A helmet
- Always
- Most of the time
- Rarely
- Never
b. Wrist guards or wrist protectors
- Always
- Most of the time
- Rarely
- Never
c. Elbow pads
- Always
- Most of the time
- Rarely
- Never
When playing ice hockey, how often do you wear a mouth guard?
Would you say:
- Always
- Most of the time
- Rarely
- Never
Current smoking status
The next questions are about cigarette smoking.
[Have you] [Has FirstName] ever smoked a whole cigarette?
Include cigarettes that are self-made.
Exclude e-cigarettes or vapes.
How old [were you] [was he/she] when [you/he/she] smoked [your/his/her] first whole cigarette?
[Have you] [Has FirstName] smoked more than 100 cigarettes (about 4 packs) in [your/his/her] life?
In the past 30 days, how often did [you/he/she] smoke cigarettes?
Would you say:
- Every day
- Less than once a day, but at least once a week
- Less than once a week, but at least once in the past month
- Not at all
How many cigarettes [do/does] [you/he/she] usually smoke each day?
In the past 30 days, how many days [have you] [has he/she] smoked one or more cigarettes?
On the days that [you/FirstName] [do/does] smoke, how many cigarettes [do/does] [you/he/she] usually smoke?
In the past 12 months, did [you/FirstName] stop smoking for at least 24 hours because [you/he/she] [were/was] trying to cut back or quit?
Smoking – past use
[Have you] [Has FirstName] ever smoked cigarettes daily?
When did [you/he/she] stop smoking?
Was it:
- Less than one year ago
- 1 year to less than 2 years ago
- 2 years to less than 3 years ago
- 3 or more years ago
At what age did [you/he/she] begin to smoke cigarettes daily?
When [you/FirstName] smoked every day, how many cigarettes did [you/he/she] usually smoke each day?
When did [you/he/she] stop smoking daily?
Was it:
- Less than one year ago
- 1 year to less than 2 years ago
- 2 years to less than 3 years ago
- 3 or more years ago
Was that when [you/he/she] completely quit smoking?
When did [you/he/she] stop completely?
Was it:
- Less than one year ago
- 1 year to less than 2 years ago
- 2 years to less than 3 years ago
- 3 or more years ago
During the past 12 months, did [you/he/she] do any of the following to help [you/him/her] quit smoking?
Select all that apply.
Would you say:
- Use nicotine replacement products
e.g., nicotine patch, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine lozenge, nicotine mouth spray
- Use a tobacco-free nicotine pouch
These products are sometimes called "white pouches", e.g., Zonnic®, Zyn®, On!®, Dryft®, Lyft®, Skruf®. These products do not contain tobacco; they are smokeless and spit-free.
- Use smoking cessation medications
e.g., Zyban®, Wellbutrin® or Champix®
- Use an internet-based program or an app
- Use a vaping device or e-cigarette
- Make a deal with a friend or [your/his/her] family
- Reduce the number of cigarettes
- Try to quit smoking on [your/his/her] own
- Other
During the past 12 months, did [you/he/she] do any of the following to help [you/him/her] when [you/he/she] quit smoking completely?
Select all that apply.
Would you say:
- Use nicotine replacement products
e.g., nicotine patch, nicotine gum, nicotine inhaler, nicotine nasal spray, nicotine lozenge, nicotine mouth spray
- Use a tobacco-free nicotine pouch
These products are sometimes called "white pouches", e.g., Zonnic®, Zyn®, On!®, Dryft®, Lyft®, Skruf®. These products do not contain tobacco; they are smokeless and spit-free.
- Use smoking cessation medications
e.g., Zyban®, Wellbutrin® or Champix®
- Use an internet-based program or an app
- Use a vaping device or e-cigarette
- Make a deal with a friend or [your/his/her] family
- Reduce the number of cigarettes
- Try to quit smoking on [your/his/her] own
- Other
Smoking – stages of change
Are you seriously considering quitting smoking within the next 6 months?
Tobacco products alternatives
The next questions are about tobacco products other than cigarettes.
In the past 30 days, did you smoke any little cigars or cigarillos?
Were these plain, flavoured or both?
In the past 30 days, did you use any of the following tobacco products other than cigarettes?
a. Cigars
Exclude little cigars or cigarillos.
b. A pipe
c. Chewing tobacco, pinch or snuff
d. A tobacco water-pipe
e.g., hookah, shisha, nargileh, hubble-bubble or gouza
e. A heated tobacco product, also known as a "heat-not-burn" product
Electronic cigarettes and vaping
Now some questions about electronic cigarettes (e-cigarettes) or vaping devices.
[Have you] [Has FirstName] ever tried an e-cigarette or vaping device, also known as a vape?
Include vaping e-liquid with nicotine and without nicotine i.e., just flavouring.
Exclude vaping cannabis.
At what age did [you/he/she] first use an e-cigarette or vaping device, also known as a vape?
In the past 30 days, how often did [you/he/she] use an e-cigarette or vaping device, also known as a vape?
Would you say:
- Every day
- Almost every day
- At least once a week
- At least once in the past month
- Not at all
The last time [you/he/she] used an e-cigarette or vaping device, also known as a vape, what did it contain?
Was it:
- An e-cigarette or a vaping device with nicotine
- An e-cigarette or a vaping device without nicotine
e.g., just flavouring
- An e-cigarette or a vaping device but [you/he/she] did not know what it contained
During the past 30 days, on how many days did [you/he/she] vape an e-cigarette or a vaping device with nicotine?
Number of days
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
During the past 30 days, on how many days did [you/he/she] vape an e-cigarette or a vaping device without nicotine?
Number of days
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
During the past 30 days, on how many days did [you/he/she] vape an e-cigarette or a vaping device but [you/he/she] did not know what it contained?
Number of days
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
In the past 30 days, which one of these flavours did [you/he/she] use most often?
Was it:
- Tobacco
- Fruit
- Candy
- Dessert
- Mint or menthol
- Coffee or tea
- Alcohol
- Flavourless
- No usual flavour
- Other
Which did [you/he/she] try first, an e-cigarette or vaping device, or a cigarette?
- E-cigarette or vaping device
- Cigarette
Cannabis use
The next few questions are about the use of cannabis for medical and non-medical purposes. The term "cannabis" refers to marijuana, hashish, hash oil or any other product of the cannabis plant.
Have you ever used or tried cannabis?
Have you used or tried cannabis just once or more than once?
At what age did you first try cannabis?
Have you used cannabis in the past 12 months?
How often did you use cannabis in the past 12 months?
Report the average use in the last 12 months.
Would you say:
- Less than once a month
- 1 to 3 times a month
- Once a week
- More than once a week
- Daily or almost daily
In the past 12 months, which of the following methods did you use to consume cannabis?
Select all that apply.
Would you say:
- Smoked
e.g., joint, pipe, bong
- Vaporized
- Swallowed
e.g., in food, beverages, capsules
- Absorbed
e.g., placed under the tongue, applied to skin
- Other
Which cannabis preparation did you vaporize?
Select all that apply.
- Dried flower or leaf
- Cannabis liquid
- Cannabis solid
In the past 12 months, which of the following methods did you use most often to consume cannabis?
Would you say:
- Smoked
- Vaporized
- Swallowed
- Absorbed
- Other method
In the past 12 months, which of the following cannabis products have you used?
Select all that apply.
Would you say:
- Dried flower or leaf
- Hashish
e.g., hash, hash oil
- Cannabis oil for oral use
e.g., capsules, spray, tincture
- Cannabis vape pens or cartridges
- Cannabis concentrates
e.g., shatter, budder, butane honey oil
- Cannabis edible food products
e.g., baked goods, candy, other foods
- Cannabis beverages
e.g., cola, tea, coffee
- Topicals
e.g., lotion, ointment, creams applied to skin
- Other
e.g., seeds
In the past 12 months, for which of the following purposes have you used cannabis?
Would you say:
- Non-medical purposes only
- Medical purposes only
Either with or without a medical document.
- Both medical and non-medical purposes
In the past 12 months, when you used cannabis for medical purposes, which symptoms were you using it for?
Select all that apply.
Would you say:
- Pain
- Nausea or vomiting
- Lack of appetite or weight loss
- Headaches or migraines
- Muscle spasms or seizures
- Anxiety or depression
- Symptoms of PTSD
- Problems sleeping
- Opioid withdrawal symptoms
- Other
Do you have a medical document from a healthcare professional to use cannabis for medical purposes?
In the past 30 days, on how many days did you use cannabis?
Would you say:
- Never
- 1 day
- 2 or 3 days
- 1 or 2 days per week
- 3 or 4 days per week
- 5 or 6 days per week
- Daily
At what age did you begin to use cannabis daily or almost daily?
In the past 12 months, have you experienced any adverse or negative health effects from using cannabis?
Select all that apply.
Would you say:
- Nausea or vomiting
- Heart or blood pressure problems
- Feeling faint or dizzy or passing out
- Panic reactions
- Hallucinations or psychosis
- Flashbacks
- Depression
- Dissociation or depersonalization
Feeling detached or disconnected from yourself or those around you.
- Lung or breathing problems
- Other
OR
- No adverse or negative health effects experienced from using cannabis
In the past 12 months, did you seek medical help for any adverse or negative health effects caused by using cannabis?
Where did you seek medical help?
Include both in-person and virtual consultations, such as over the telephone, by video, or by written correspondence.
Select all that apply.
- A poison centre
- A family doctor or other health care provider's office
- A walk-in clinic
- A community health centre [or CLSC]
Include nursing stations.
- A telephone health service or helpline
e.g., Health Links, Health Connect Ontario, Health811, Health-Line, TeleCare, Info-Santé
- Addiction support services
- A hospital emergency room
- Other
Severity of dependence scale for cannabis
You may feel like some of the following questions do not apply to you; however, it is important that they be asked in this survey.
In the past 12 months, how often did you feel the following?
a. Your use of cannabis was out of control
- Never or almost never
- Sometimes
- Often
- Always or nearly always
b. The idea of missing a dose of cannabis made you anxious or worried
- Never or almost never
- Sometimes
- Often
- Always or nearly always
c. You worried about your use of cannabis
- Never or almost never
- Sometimes
- Often
- Always or nearly always
d. You wished you could stop using cannabis
- Never or almost never
- Sometimes
- Often
- Always or nearly always
How difficult would it be for you to stop or go without using cannabis?
Would you say:
- Not difficult
- Quite difficult
- Very difficult
- Impossible
Alcohol use
Now some questions about alcohol consumption.
[Have you] [Has FirstName] ever had a drink in [your/his/her] lifetime?
[A "drink" refers to: a small bottle, draft or can of beer, cider or cooler; a glass of wine; a cocktail or glass containing 1.5 ounces of liquor.]
In the past 12 months, [have you] [has he/she] had a drink of beer, wine, liquor or any other alcoholic beverage?
In the past 12 months, how often did [you/he/she] drink alcoholic beverages?
- Less than once a month
- Once a month
- 2 to 3 times a month
- Once a week
- 2 to 3 times a week
- 4 to 5 times a week
- Daily or almost daily
How often in the past 12 months [have you] [has he/she] had [4/5] or more drinks on one occasion?
- Never
- Less than once a month
- Once a month
- 2 to 3 times a month
- Once a week
- More than once a week
In the past 7 days, that is from [Date7DaysAgo] to yesterday, did [you/FirstName] have a drink of beer, wine, liquor or any other alcoholic beverage?
In the past 7 days, that is from [Date7DaysAgo] to yesterday, how many drinks did [you/he/she] have each day?
a. [DateYesterday]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
b. [Date2DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
c. [Date3DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
d. [Date4DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
e. [Date5DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
f. [Date6DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
g. [Date7DaysAgo]
Number of drinks per day
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50 or more
Gambling
The following questions are about various types of gambling activities. Please think about all forms of gambling done either in person or online, including lotteries, organized betting and casual wagers with friends. Please include any location, whether at a casino, a private residence, online or anywhere else.
In the past 12 months, how often have you purchased or played the following gambling activities?
a. Instant lottery tickets, such as scratch, break-open or pull-tabs, or instant online games
Include instant games only.
Exclude lotteries such as Lotto Max or 6/49.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
b. Lottery or raffle tickets
Include Lotto 6/49, Lotto Max, Daily Grand, provincial and regional lotteries, hospital lotteries, 50-50 tickets.
Exclude sports lottery tickets.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
c. Electronic gambling machines, such as slot machines, video lottery terminals (VLTs), electronic blackjack, electronic roulette or video poker, either in person or online
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
d. Casino table games like poker, blackjack, baccarat, or roulette
Include craps, mah-jong, sic bo or pai gow.
Exclude electronic machine versions.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
e. Sports such as hockey, football, horseracing, billiards or golf including pools, sports lottery, and bets made with friends
Include sports lottery tickets, e-sports, fantasy sports, virtual sports and sports you participate in yourself.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
f. Bingo
Exclude instant bingo games on scratch tickets or electronic machine versions of bingo.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
g. Other forms of gambling
e.g., keno, animal fights, dog racing, non-casino card or dice games such as rummy or backgammon, video games, board games, political events, and television events like reality or award show winners
Exclude speculative financial market activities such as cryptocurrency.
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
For the types of gambling that you reported participating in, has your involvement been in-person, online or both?
Include online purchase of lottery tickets.
In the past 12 months, what is the largest amount of money you have lost to gambling on any single day?
Would you say:
- $1 to $49
- $50 to $199
- $200 to $499
- $500 to $999
- $1,000 and more
In the past 12 months, how much do you estimate you spent on gambling?
Would you say:
- $1 to $99
- $100 to $299
- $300 to $999
- $1,000 to $4,999
- $5,000 to $9,999
- $10,000 and more
- You have won more than you lost in the past 12 months
In the past 12 months, how often have you engaged in any speculative financial market activities such as buying cryptocurrency like Bitcoin or Ethereum, day trading, penny stocks, shorting, options, currency futures?
Would you say:
- Never
- Less than once a month
- Once a month
- Two or three times a month
- Once a week
- Several times a week
You may feel like some of the following questions do not apply to you; however, it is important that they are asked in this survey.
In the past 12 months, how often have you done or felt the following?
a. Bet more than you could really afford to lose
- Never
- Sometimes
- Most of the time
- Almost always
b. Needed to gamble with larger amounts of money to get the same feeling of excitement
- Never
- Sometimes
- Most of the time
- Almost always
c. Went back another day to try to win back the money you lost
- Never
- Sometimes
- Most of the time
- Almost always
d. Borrowed money or sold anything to get money to gamble
- Never
- Sometimes
- Most of the time
- Almost always
e. Your gambling caused any financial problems for you or your household
- Never
- Sometimes
- Most of the time
- Almost always
f. Felt that you might have a problem with gambling
- Never
- Sometimes
- Most of the time
- Almost always
g. Your gambling caused you any health problems, including stress or anxiety
- Never
- Sometimes
- Most of the time
- Almost always
h. People criticized your betting or told you that you had a gambling problem, regardless of whether or not you thought it was true
- Never
- Sometimes
- Most of the time
- Almost always
i. Felt guilty about the way you gamble or what happens when you gamble
- Never
- Sometimes
- Most of the time
- Almost always
Parental experiences
Is there a child living in this household who is 5 years old or younger?
Would you say:
- Yes, there is one child who meets this definition
- What is this child's first name?
- Yes, there is more than one child who meets this definition e.g., twins, or there is more than one child five years or younger in the household
- What is the last-born child's first name?
Refer to the last baby born between [FiveYearsAgo] and [Today]
- No, there are no children who meet this definition
What is [BabyName/this child]'s date of birth?
- Day
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- Month
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
- Year
- 2026
- 2025
- 2024
- 2023
- 2022
- 2021
- 2020
- 2019
Was [BabyName/this child] a single birth or a multiple birth?
- Single birth
- Multiple birth
e.g., twins
The next questions are specific to [BabyName/this child].
Did you give birth to [BabyName/this child]?
During the three months before your pregnancy with [BabyName/this child], did you take a vitamin supplement containing folic acid?
Include prenatal vitamins, multivitamins or single supplements.
During the first trimester or the first three months of your pregnancy with [BabyName/this child], did you take a vitamin supplement containing folic acid?
Include prenatal vitamins, multivitamins or single supplements.
During your pregnancy with [BabyName/this child], did you take a vitamin or mineral supplement containing iron?
Include prenatal vitamins, multivitamins or single supplements.
Exclude intravenous (IV) iron infusion.
Just before your pregnancy with [BabyName/this child], how much did you weigh?
- Weight
- Pounds or kilograms
How much weight did you gain during your pregnancy with [BabyName/this child]?
If you lost weight, enter a negative value.
- Weight gained
- Pounds or kilograms
Did anyone regularly smoke in your presence during your pregnancy with [BabyName/this child]?
Are you [BabyName/this child]'s parent or one of the main people responsible for their care?
e.g., biological, non-biological, adoptive, and step parents or guardians
Was [BabyName/this child] ever breastfed or given any amount of breast milk, even for a short time?
Include colostrum, expressed breast milk, and breast milk from a donor or donor milk bank.
What is the main reason that [BabyName/this child] was not breastfed or given breast milk?
Would you say:
- Formula feeding was easier
- Formula was as good as breast milk
- Breastfeeding was unappealing
- Medical condition – mother
- Not enough support or information to breastfeed
- Return to work or school
- Previously unsuccessful experience with breastfeeding
- Other
Is [BabyName/this child]still breastfeeding or being given breast milk?
Include colostrum, expressed breast milk, and breast milk from a donor or donor milk bank.
How old was [BabyName/this child] when they stopped breastfeeding or receiving breast milk?
You can report the age in days, weeks, months or years.
- Age
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- Time period
What is the main reason that [BabyName/this child] stopped receiving breast milk?
Would you say:
- Not enough breast milk
- Inconvenience or fatigue due to breastfeeding
- Difficulty with breastfeeding
- Medical condition - mother
- Medical condition - baby
- Planned to stop at this time
- Child weaned themselves
- Return to work or school
- Not enough support or information to breastfeed
- Other
[Is [BabyName/this child]receiving/When [BabyName/this child] was less than a year old, did they receive/When [BabyName/this child] was less than one year old and fed breast milk, did they receive/When [BabyName/this child] was fed breast milk, did they receive] a vitamin D supplement?
Would you say:
- Every day or almost every day
- Occasionally
- Never
Now that [BabyName/this child] is more than a year old, are they receiving a vitamin D supplement?
Would you say:
- Every day or almost every day
- Occasionally
- Never
[Have/While still being given breast milk, had] other liquids been introduced to [BabyName/this child]'s diet?
e.g., formula, cow's milk, soy milk, water or juice
Exclude breast milk.
Exclude any formula supplementation that only occurred during the first week after birth.
What was the first liquid introduced?
Would you say:
- Formula
- Cow's milk
- Soy milk
- Water
- Juice
- Other
How old was [BabyName/this child] when other liquids were first introduced?
e.g., formula, cow's milk, soy milk, water or juice
Exclude breast milk.
Exclude any formula supplementation that only occurred during the first week after birth.
You can report the age in days, weeks, months or years.
- Age
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- Time period
Have solid foods been introduced to [BabyName/this child]'s diet?
e.g., cereals, meat, vegetables or fruits
What was the first solid food?
Would you say:
- Infant cereals
- Fruits or vegetables
- Meat or meat alternatives
Include eggs, tofu, legumes, peas or lentils.
How old was [BabyName/this child] when solids were first added?
You can report the age in days, weeks, months or years.
- Age
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
- 21
- 22
- 23
- 24
- 25
- 26
- 27
- 28
- 29
- 30
- 31
- 32
- 33
- 34
- 35
- 36
- 37
- 38
- 39
- 40
- 41
- 42
- 43
- 44
- 45
- 46
- 47
- 48
- 49
- 50
- 51
- 52
- 53
- 54
- 55
- 56
- 57
- 58
- 59
- 60
- 61
- 62
- 63
- 64
- 65
- 66
- 67
- 68
- 69
- 70
- 71
- 72
- Time period
[How often does [BabyName/this child]/ When [BabyName/this child] was less than one year old, how often did they] sleep in the same bed with you or anyone else?
Would you say:
- Every day or almost every day
- Occasionally
- Never
When [BabyName/this child] was less than 4 months old, how often did they sleep in the same bed with you or anyone else?
Would you say:
- Every day or almost every day
- Occasionally
- Never
Maternal experiences – alcohol use during pregnancy
In the 3 months before your pregnancy with [BabyName/this child], or before you realized you were pregnant, did you drink alcohol?
How often did you drink?
- A few times a month or less
- Once or twice a week
- Many times a week
- Everyday
On the days you did drink, how many drinks did you usually have?
- One drink
- Two drinks
- Three drinks
- More than three drinks
Once you found out you were pregnant with [BabyName/this child], did you drink alcohol?
How often did you drink?
- A few times a month or less
- Once or twice a week
- Many times a week
- Everyday
On the days you did drink, how many drinks did you usually have?
- One drink
- Two drinks
- Three drinks
- More than three drinks
[While you were still breastfeeding [BabyName/this child], did/Since giving birth to [BabyName/this child], do] you drink alcohol?
How often [did/do] you drink?
- A few times a month or less
- Once or twice a week
- Many times a week
- Everyday
On the days you [did/do] drink, how many drinks [did/do] you usually have?
- One drink
- Two drinks
- Three drinks
- More than three drinks
Maternal experiences – smoking during pregnancy
In the 3 months before your pregnancy with [BabyName/this child], or before you realized you were pregnant, did you smoke cigarettes?
How often did you smoke?
Would you say:
- Everyday
- Almost everyday
- A few times a week
- Rarely
Once you found out you were pregnant with [BabyName/this child], did you smoke?
How often did you smoke?
Would you say:
- Everyday
- Almost everyday
- A few times a week
- Rarely
Pap smear test
Now some questions about the Pap smear test.
Have you ever had a Pap smear test?
When was the last time?
Would you say:
- Less than 1 year to 1 year ago
- More than 1 year to 2 years ago
- More than 2 years to 3 years ago
- More than 3 years to 5 years ago
- More than 5 years ago
What are the reasons that you have not had a Pap smear test in the past 3 years?
Select all that apply.
Would you say:
- Lack of time
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- [Had a complete hysterectomy]
- Did not know it existed or that it was a possibility
- Had an HPV test instead
- Other
How often do you usually have a Pap smear test?
Would you say:
- It was the first time
- More than once a year
- Between once a year to less than every 3 years
- Every 3 years
- Less often than every 3 years
- No fixed frequency
High-risk types of human papillomavirus (HPV) cause changes in the cells of the cervix that can be detected on a Pap test as abnormal changes. The HPV test is an additional tool used to show the presence of a high-risk type of HPV.
This test is not a Pap test but is collected in a similar way. An HPV test can be done at the same time as a Pap test or instead of a Pap test. It can be administered by your health care provider or by self-sampling at home.
Have you ever had an HPV test?
Mammography
Have you ever had a mammogram, that is, a breast x-ray?
A person with a high-risk status based on a family or medical history could have a mammogram at an earlier age than the general guidelines stipulated by their province or territory.
When was the last time?
Would you say:
- Less than 1 year to 1 year ago
- More than 1 year to 2 years ago
- More than 2 years to 3 years ago
- More than 3 years to 5 years ago
- More than 5 years ago
What were the reasons for having this mammogram?
Select all that apply.
- Family history of breast cancer
- Part of routine screening
- Age
- Previously detected lump
- Follow-up of breast cancer treatment
- On hormone replacement therapy
- Breast problem
- Other
What are the reasons you have not had a [mammogram/mammogram in the past 3 years]?
Select all that apply.
Would you say:
- Lack of time
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- Had a bilateral mastectomy
i.e., both breasts were removed
- Other
How often do you usually have this test?
Would you say:
- It was the first time
- More than once a year
- Between once a year to less than every 3 years
- Every 3 years
- Less often than every 3 years
- No fixed frequency
Colorectal cancer testing
Now a few questions about colorectal tests.
A fecal test is a test to check for blood in the stool, in which a stick is used to smear a small stool sample on a special card or a small stool sample is collected and placed inside a tube.
Have you ever had this test?
The fecal test is also called gFOBT (Guaiac-based Fecal Occult Blood Test) or FIT (Fecal Immunochemical Test).
When was the last time?
Would you say:
- 6 months ago or less
- More than 6 months to 1 year ago
- More than 1 year to 2 years ago
- More than 2 years to 5 years ago
- More than 5 years ago
What are the reasons you did not have a fecal test[ in the past 2 years]?
Select all that apply.
Would you say:
- Lack of time
- No access to test
e.g., distance, clinic hours or cost
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- Had a colonoscopy or sigmoidoscopy instead
- Did not know it existed or that it was a possibility
- Other
How often do you usually have this fecal test?
Would you say:
- It was the first time
- More than once a year
- Every year
- Every 2 years
- Less than every 2 years
- No fixed frequency
A sigmoidoscopy and a colonoscopy are two tests in which a tube is inserted into the rectum in order to detect signs of cancer or other health problems.
A colonoscopy examines the entire colon, while a sigmoidoscopy only examines the first section of the colon. The sigmoidoscopy requires less preparation.
Have you ever had either one of these tests?
The sigmoidoscopy can be performed by a nurse or non-specialist physician. The colonoscopy preparation requires fasting and drinking a large quantity of liquid to empty the colon.
What are the reasons you have not had these tests?
Select all that apply.
Would you say:
- Lack of time
- No access to test
e.g., distance, clinic hours or cost
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- [Had a fecal test instead]
- Did not know it existed or that it was a possibility
- Other
Which of these tests have you had[, a colonoscopy, a sigmoidoscopy or both]?
Would you say:
- Colonoscopy
Examines the entire colon.
- Sigmoidoscopy
Examines the first section of the colon and requires less preparation.
- Both
When was the last time you had a sigmoidoscopy?
Would you say:
- 1 year ago or less
- More than 1 year to 2 years ago
- More than 2 years to 5 years ago
- More than 5 years to 10 years ago
- More than 10 years ago
What are the reasons you have not had this test in the past 10 years?
Select all that apply.
Would you say:
- Lack of time
- No access to test
e.g., distance, clinic hours or cost
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- [Had a different colorectal test instead]
- Did not know it existed or that it was a possibility
- Other
How often do you usually have this test?
Would you say:
- It was the first time
- More than once every 5 years
- Every 5 years
- Less than once every 5 years
- No fixed frequency
When was the last time you had a colonoscopy?
Would you say:
- 1 year ago or less
- More than 1 year to 2 years ago
- More than 2 years to 5 years ago
- More than 5 years to 10 years ago
- More than 10 years ago
What are the reasons you have not had this test in the past 10 years?
Select all that apply.
Would you say:
- Lack of time
- No access to test
e.g., distance, clinic hours or cost
- Did not think it was necessary
- Health care provider did not think it was necessary, never brought it up
- Feelings of fear or discomfort
- Don't have a health care provider
- [Had a different colorectal test instead]
- Did not know it existed or that it was a possibility
- Other
How often do you usually have this test?
Would you say:
- It was the first time
- More than once every 10 years
- Every 10 years
- Less than once every 10 years
- No fixed frequency
Was the colonoscopy or sigmoidoscopy a follow-up of the results of a fecal test?
Were you prescribed [a colonoscopy/a sigmoidoscopy/one of these tests] because of a family history of colorectal cancer, an inflammatory bowel disease, a colorectal cancer follow-up or symptoms of colorectal cancer?
e.g., you previously had colorectal cancer or polyps, have a history of colorectal cancer in at least one first degree blood relative, have an inflammatory bowel disease, have other symptoms indicating a predisposition to colorectal cancer.
Flu shots
Now a few questions about the flu vaccine.
In the past 12 months, have you had a seasonal flu vaccine?
Seasonal flu vaccine can be administered either by a needle, called a flu shot, or by a nasal spray called FluMist®.
In which month did you have your last seasonal flu vaccine?
Month
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
Was that this year or last year?
What are the reasons that you did not have a seasonal flu vaccine in the past 12 months?
Select all that apply.
- Did not think it was necessary
- Concern about discomfort or side effects
- Flu is not that severe
- Flu vaccine does not work that well
- Previously had a bad reaction to the flu vaccine or other vaccine
- Other
Vaccines
Excluding COVID-19 and flu vaccines, how likely are you to receive a vaccine if it is recommended to you by a health care provider?
e.g., routine or travel vaccines or vaccines for high-risk populations
- Very likely
- Somewhat likely
- Somewhat unlikely
- Very unlikely
Regular health care provider
Now, here are some questions about primary health care. This type of health care is often delivered by family doctors or nurse practitioners.
[Do you] [Does FirstName] have a regular health care provider? By this, we mean a primary health care professional that [you/he/she] can consult with when [you/he/she] need[s] care or advice for [your/his/her] health.
Select "Yes, another health professional" if [you/he/she] receive[s] regular care from locums.
- Yes, a family doctor
- Yes, a nurse practitioner
- Yes, another health professional
- Specify the other health professional
- No
When [you/FirstName] consult[s] with [this family doctor/this nurse practitioner/this other health professional], [do you] [does he/she] have to pay out-of-pocket for [your/his/her] consultation because they work in a private pay model?
Exclude any fees associated with medical notes for work or school, expedited blood work, prescription renewals, cosmetic procedures, travel medicine advice and vaccines, tests requested by employers or insurance companies, and other services that are not covered by the universal health care system.
Some patients receive primary health care from a team of health professionals working together to provide coordinated services and care. In addition to family doctors and nurses, these teams could include social workers, dieticians and pharmacists, but do not include medical specialists (e.g., cardiologists, oncologists).
[Are you] [Is FirstName] a patient of a team of health professionals that work together to provide [you/him/her] with coordinated services and care?
Exclude care provided by teams of medical specialists (e.g., cardiologists, oncologists).
Depending on where [you/FirstName] live[s], these teams might be called a Family Health Team, Family Medicine Group, Integrated Care Network or Primary Care Network.
[Do you][Does he/she] have to pay out-of-pocket for any of the services provided by the team of health professionals?
Exclude any fees associated with medical notes for work or school, expedited blood work, prescription renewals, cosmetic procedures, travel medicine advice and vaccines, tests requested by employers or insurance companies, and other services that are not covered by the universal health care system.
Why [do you] [does FirstName] not have a regular health care provider?
Select all that apply.
Would you say:
- Currently on a waitlist
- [Do/Does] not need one in particular
- No one in the area is taking new patients
- There are no health care providers in the area
- [You have] [He/She has] not tried to find one
- [You/He/She] had one who left, retired, or changed practice
- [You/He/She] moved to a new area
- [You/He/She] aged out of paediatric care
Paediatric care is health care for children and youth.
- Other
- Specify the other reason [you do] [he/she does] not have a regular health care provider
The following questions are about consultations [you/FirstName] may have had in the past 12 months with a primary health care provider when [you/he/she] [were/was] sick or concerned about [your/his/her] health.
In the past 12 months, did [you/FirstName] consult a primary health care provider when [you/he/she] [were/was] sick or concerned about [your/his/her] health?
Exclude visits to the emergency department, scheduled check-ups or routine testing, and consultations with optometrists, dentists or medical specialists (e.g., cardiologists, oncologists).
Include both in-person and virtual consultations, such as over the telephone, by video, or by written correspondence.
Thinking about the most recent consultation when [you/FirstName] [were/was] sick or concerned about [your/his/her] health, was this consultation with [your/his/her] [family doctor/nurse practitioner/other health professional who is [your/his/her] regular health care provider]?
Exclude consultations with medical specialists (e.g., cardiologists, oncologists).
Include both in-person and virtual consultations, such as over the telephone, by video, or by written correspondence.
Thinking about the most recent consultation when [you/FirstName] [were/was] sick or concerned about [your/his/her] health, was this consultation with a member of the team of health professionals who provides [you/him/her] with coordinated services and care?
Exclude consultations with medical specialists (e.g., cardiologists, oncologists).
Include both in-person and virtual consultations, such as over the telephone, by video, or by written correspondence.
Thinking about the most recent consultation when [you/FirstName] [were/was] sick or concerned about [your/his/her] health, did [you/FirstName] have to pay out-of-pocket because this primary health care provider works in a private pay model?
Exclude any fees associated with medical notes for work or school, expedited blood work, prescription renewals, cosmetic procedures, travel medicine advice and vaccines, tests requested by employers or insurance companies, and other services that are not covered by the universal health care system.
Still thinking about this most recent consultation, how long did [you/FirstName] have to wait between the time [you/he/she] requested care and when [you/he/she] consulted [this primary health care provider/[your/his/her] family doctor/[your/his/her] nurse practitioner/[your/his/her] other health professional who is [your/his/her] regular health care provider/a member from [your/his/her] team of health professionals]?
Would you say:
- The same day
- The next day
- 2 to 3 days
- 4 to 6 days
- 1 week to less than 2 weeks
- 2 weeks to less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months or more
Still thinking about this most recent consultation, how satisfied were you with the time you had to wait between requesting care and when you consulted with [this primary health care provider/[your/his/her] family doctor/[your/his/her] nurse practitioner/[your/his/her] other health professional who is [your/his/her] regular health care provider/a member from [your/his/her] team of health professionals]?
Would you say:
- Very satisfied
- Satisfied
- Neither satisfied nor dissatisfied
- Dissatisfied
- Very dissatisfied
Still thinking about this most recent consultation, indicate to what extent you agree or disagree with the following statement.
I received health care that was sensitive to my cultural background and identity from [this primary health care provider/my family doctor/my nurse practitioner/my other health professional who is my regular health care provider/the member of my team of health professionals].
This is health care that makes the patient feel they are respected, safe and can trust the health care provider.
Include how you were treated based on age, sex, gender, sexual orientation, ethnicity, indigenous identity, race, language, accent, religion or spirituality, disability, or other factors.
Would you say:
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
For which reasons do you feel you did not receive health care that was sensitive to your cultural background and identity?
Select all that apply.
Would you say:
- Your ethnicity or culture
- Your Indigenous identity
- Your race or skin colour
- Your language
- Your accent
- Your religion or spirituality
- Your age
- Your sex
Refers to sex assigned at birth.
- Your gender
Refers to an individual's personal and social identity as a man, woman, or non-binary person.
- Your sexual orientation
Refers to how a person describes their sexuality.
- A disability
- Other
- Specify the other reason you disagree
OR
For which reasons do you feel you did not receive health care that was sensitive to your cultural background and identity?
Select all that apply.
Would you say:
- Your ethnicity or culture
- Your Indigenous identity
- Your race or skin colour
- Your language
- Your accent
- Your religion or spirituality
- Your age
- Your sex
Refers to sex assigned at birth.
- Your gender
Refers to an individual's personal and social identity as a man, woman, or non-binary person.
- Your sexual orientation
Refers to how a person describes their sexuality.
- A disability
- Other
- Specify the other reason you strongly disagree
OR
Electronic health information
The following questions are about your use of health technology and digital health systems in general and in relation to your own health.
Health technology includes the Internet or websites, health applications, sensors, monitoring machines, computers or laptops, mobile phones or smartphones, tablets, or smartwatches.
Digital health systems include online health records, health applications, private health insurance websites or applications, doctor's website, health care provider's website, or prescription applications.
Please indicate how strongly you disagree or agree with each of the following statements.
a. Technology makes me feel actively involved with my health
- Strongly disagree
- Disagree
- Agree
- Strongly agree
b. I know how to use technology to get the health information I need
- Strongly disagree
- Disagree
- Agree
- Strongly agree
c. I know how to make technology work for me
- Strongly disagree
- Disagree
- Agree
- Strongly agree
d. I use technology to find information about health
- Strongly disagree
- Disagree
- Agree
- Strongly agree
e. I can enter data into health technology systems
- Strongly disagree
- Disagree
- Agree
- Strongly agree
f. I often use technology to understand health problems
- Strongly disagree
- Disagree
- Agree
- Strongly agree
g. Technology helps me decide what health care is best for me
- Strongly disagree
- Disagree
- Agree
- Strongly agree
h. I quickly learn how to find my way around new technology
- Strongly disagree
- Disagree
- Agree
- Strongly agree
i. I find technology helps me take care of my health
- Strongly disagree
- Disagree
- Agree
- Strongly agree
j. I use technology to share information about my health
- Strongly disagree
- Disagree
- Agree
- Strongly agree
k. I find I get better services from my health professionals when I use technology
- Strongly disagree
- Disagree
- Agree
- Strongly agree
l. I use technology to organise my health information
- Strongly disagree
- Disagree
- Agree
- Strongly agree
m. Technology improves my communication with health professionals
- Strongly disagree
- Disagree
- Agree
- Strongly agree
n. I easily learn to use new health technologies
- Strongly disagree
- Disagree
- Agree
- Strongly agree
o. I find technology useful for monitoring my health
- Strongly disagree
- Disagree
- Agree
- Strongly agree
The following questions are about whether you can access your own health information online through websites, applications or portals.
This information may be provided by health authorities, hospitals, doctors, laboratories, pharmacies or other health professionals.
Which of the following types of information about your health do you have access to through websites, applications, or portals?
Select a category even if you have access to some, but not all of this type of health information electronically.
e.g., select "Laboratory test results" if you can access some, but not all of your laboratory test results electronically.
Select all that apply.
Would you say:
- Laboratory test results
- COVID-19 vaccine records
- Vaccine or immunization records other than for COVID-19
- Current medications and medication history
Include requests for prescription renewals.
- Patient visit summaries
- Specialist consultation notes or records
- Upcoming appointments
- Forms and questionnaires
- Progress notes
- Discharge summaries
- Medical imaging reports
- Other health information
- Specify the other health information you have access to
OR
Mental health
The following questions deal with problems you may have had during the last two weeks.
Over the last 2 weeks, how often have you been bothered by any of the following problems?
a. Had little interest or pleasure in doing things
- Not at all
- Several days
- More than half the days
- Nearly every day
b. Felt down, depressed, or hopeless
- Not at all
- Several days
- More than half the days
- Nearly every day
c. Had trouble falling or staying asleep, or sleeping too much
- Not at all
- Several days
- More than half the days
- Nearly every day
d. Felt tired or having little energy
- Not at all
- Several days
- More than half the days
- Nearly every day
e. Had poor appetite or overate
- Not at all
- Several days
- More than half the days
- Nearly every day
f. Felt bad about yourself — or that you are a failure or have let yourself or your family down
- Not at all
- Several days
- More than half the days
- Nearly every day
g. Had trouble concentrating on things, such as reading the newspaper or watching television
- Not at all
- Several days
- More than half the days
- Nearly every day
h. Been moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual
- Not at all
- Several days
- More than half the days
- Nearly every day
i. Had thoughts that you would be better off dead or of hurting yourself in some way
- Not at all
- Several days
- More than half the days
- Nearly every day
How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Would you say:
- Not difficult at all
- Somewhat difficult
- Very difficult
- Extremely difficult
Suicide
The next few questions are about things that may have happened to you at any time and might be hard for you to answer. Your responses are important whether or not you have had any of these experiences. Remember that all information provided is strictly confidential.
These questions ask about sad feelings and attempted suicide. Sometimes people feel so depressed about the future that they may consider attempting suicide, that is, taking some action to end their own life.
During the past 12 months, did you ever seriously consider attempting suicide or taking your own life?
Have you ever attempted suicide or tried taking your own life?
During the past 12 months, did you ever attempt suicide or try taking your own life?
Thinking of the most recent time you attempted suicide or tried taking your own life, did this result in an injury or poisoning?
Did you require medical attention?
Positive mental health
The following questions are about how you have been feeling during the past 2 weeks.
a. I've been feeling optimistic about the future
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
b. I've been feeling useful
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
c. I've been feeling relaxed
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
d. I've been feeling interested in other people
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
e. I've had energy to spare
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
f. I've been dealing with problems well
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
g. I've been thinking clearly
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
h. I've been feeling good about myself
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
i. I've been feeling close to other people
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
j. I've been feeling confident
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
k. I've been able to make up my own mind about things
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
l. I've been feeling loved
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
m. I've been interested in new things
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
n. I've been feeling cheerful
- None of the time
- Rarely
- Some of the time
- Often
- All of the time
Social provisions
The next questions are about your current relationships with friends, family members, co-workers, community members and so on.
Please indicate to what extent each statement describes your current relationships with other people.
a. I have close relationships that provide me with a sense of emotional security and wellbeing
- Strongly agree
- Agree
- Disagree
- Strongly disagree
b. There is someone I could talk to about important decisions in my life
- Strongly agree
- Agree
- Disagree
- Strongly disagree
c. I have relationships where my competence and skill are recognized
- Strongly agree
- Agree
- Disagree
- Strongly disagree
d. I feel part of a group of people who share my attitudes and beliefs
- Strongly agree
- Agree
- Disagree
- Strongly disagree
e. There are people I can count on in an emergency
- Strongly agree
- Agree
- Disagree
- Strongly disagree
Sources of stress
Now a few questions about the stress in your life.
In general, how would you rate your ability to handle unexpected and difficult problems, for example, a family or personal crisis?
Would you say:
In general, how would you rate your ability to handle the day-to-day demands in your life, for example, handling work, family and volunteer responsibilities?
Would you say:
Thinking about stress in your day-to-day life, what would you say is the most important thing contributing to feelings of stress you may have?
Would you say:
- Work
- Financial concerns
- Family
- School work
- Time pressures or not enough time
- Health
- Other
- Specify other source of stress
- None
Perceived need for care
The following questions deal with the different kinds of professional help you received, or thought you needed, for your emotions, mental health or use of alcohol or drugs.
During the past 12 months, did you receive any form of professional help for your emotions, mental health or use of alcohol or drugs?
This could include counseling, therapy, help with interpersonal relationships, or prescription medication.
Which type of professional help did you receive?
Select all that apply.
Was it:
- Counseling or therapy
- Prescription medication
- Other
- Specify other professional help
You mentioned that you received professional help for your emotions, mental health or use of alcohol or drugs. Do you think you received all the help you needed during the past 12 months?
Why do you think you did not receive all the help you needed during the past 12 months?
Select all that apply.
Would you say:
- You preferred to manage yourself
- You didn't know how or where to get help
- You were too busy
- Your job interfered
e.g., workload, hours of work or no cooperation from supervisor
- Help was not readily available
e.g., long wait lists
- Help was not available where you live
- You had trouble finding or affording transportation
- Help did not meet your needs
- You didn't have confidence in the health care system or social services
- You couldn't afford to pay
- You were afraid of what others would think of you
- Language or cultural barriers
- Other
You mentioned that you did not receive any professional help for your emotions, mental health or use of alcohol or drugs. Do you think you needed this kind of help during the past 12 months?
Why do you think you did not receive all the help you needed during the past 12 months?
Select all that apply.
Would you say:
- You preferred to manage yourself
- You didn't know how or where to get help
- You were too busy
- Your job interfered
e.g., workload, hours of work or no cooperation from supervisor
- Help was not readily available
e.g., long wait lists
- Help was not available where you live
- You had trouble finding or affording transportation
- Help did not meet your needs
- You didn't have confidence in the health care system or social services
- You couldn't afford to pay
- You were afraid of what others would think of you
- Language or cultural barriers
- Other
Consultations on mental health
The following questions are about mental and emotional well-being.
In the past 12 months, have you seen or talked to a health professional about your emotional or mental health?
Include both face-to-face and telephone contacts.
How many times in the past 12 months did you see or talk to the following health professionals about your emotional or mental health?
a. Family doctor or general practitioner
b. Psychiatrist
c. Psychologist
d. Nurse
e. Social worker or counsellor
f. Other
Oral health
Now a few questions about dental care.
In the past 12 months, how often have you had any persistent or ongoing mouth pain?
Include pain in teeth, gums, tongue, jaw, or jaw joints.
Would you say:
- Often
- Sometimes
- Rarely
- Never
- Don't know
Do you have any untreated mouth problems?
Mouth problems are defined as any condition that causes pain or discomfort.
For example:
- abscesses
- gum issues such as pain and bleeding
- jaw pain; temporomandibular joints (TMJ)
- untreated cavities, fillings needing to be replaced
- tooth pain
- injuries
- mouth sores.
Exclude braces or other orthodontic treatments.
When was the last time you saw a dentist, denturist, dental hygienist or any other dental specialist?
Services may have been provided in any setting where the oral health professional is licensed to practice.
Would you say:
- Less than one year ago
- 1 year to less than 3 years ago
- 3 years ago or more
- Never seen an oral health professional
- Don't know
Now a few questions about the cost of your dental care.
In the past 12 months, have you avoided going to an oral health professional for your dental care due to the cost of care?
In the past 12 months, were there any [other] reasons that you did not get dental care or treatment?
Select all that apply.
Would you say:
- Did not feel it was necessary
- Could not afford to pay up front for the services and wait for the reimbursement
- Could not afford to pay for the cost of the services that are not covered by insurance
- Indirect costs
e.g., childcare, transportation
- Service not available in your area
- There was a waitlist
- Oral health professional office was not open at a convenient time
- Afraid or anxious or do not like receiving oral health care
- Unable to take time off from work
- Too busy
- Expected oral health problems to go away on their own
- Other reason
- Specify other reason
OR
- I received all the necessary dental care or treatment
OR
COVID-19 – vaccination
Since the start of the COVID-19 pandemic, how many COVID-19 vaccine doses have you received (e.g., Johnson & Johnson, Moderna, Pfizer-BioNTech, AstraZeneca, Novavax)?
Include all COVID-19 primary series as well as any booster doses.
All doses of COVID-19 vaccines after the primary series are described as booster doses.
Exclude doses you are scheduled for but have not received yet.
Number of vaccine doses
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 19
- 20
When did you receive your most recent COVID-19 vaccine dose?
If the exact date is not known, please provide your best estimate.
- Month
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
- Year
- 2020
- 2021
- 2022
- 2023
- 2024
- 2025
- 2026
If an annual booster dose for COVID-19 is recommended by the Public Health Agency of Canada or your provincial or territorial government, how likely are you to get it every year?
All doses of COVID-19 vaccines after the primary series are described as booster doses.
Would you say:
- Very likely
- Somewhat likely
- Somewhat unlikely
- Very unlikely
COVID-19 – infections
Since the start of the COVID-19 pandemic, how many different COVID-19 infections did you think or know you have had?
Include infections with a positive test result (e.g., PCR or rapid antigen test) and infections you suspected were COVID-19 because of your symptoms or recent contact with a COVID-19 case.
Number of infections
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
- 11
- 12
- 13
- 14
- 15
- 16
- 17
- 18
- 19
- 20
When did you experience your [most recent] COVID-19 infection?
If the exact date is not known, please provide your best estimate.
- Month
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
- Year
- 2020
- 2021
- 2022
- 2023
- 2024
- 2025
- 2026
COVID-19 – symptoms
[Some people may experience more than one COVID-19 infection. When answering the following questions, think about all the times you experienced COVID-19.]
Three or more months after you thought or knew that you had COVID-19, did you experience any symptoms that could not be explained by anything else?
Include symptoms from your COVID-19 infection that lasted three or more months, or symptoms that developed after recovering from COVID-19.
Would you say:
- Three months have not passed since you thought or knew that you had COVID-19 for the first time
- Yes
- No
Since the start of the pandemic, did you experience any new unexplained symptoms lasting two or more months?
Do you continue to experience any of these symptoms?
For approximately how many months did you experience one or more of these symptoms?
Indicate the total number of months from when you first experienced any symptom until [today/they ended]. If you are uncertain, please provide your best estimate.
When your symptoms [are/were] at their worst, how often [do/did] they limit your daily activities?
When answering, consider the combined impact of all your symptoms.
Daily activities include preparing meals, everyday household chores, getting to appointments and running errands, looking after your personal finances, personal care, basic medical care at home and moving around inside your residence.
Would you say:
- Never
- Rarely
- Sometimes
- Often
- Always
Overall, since you started having these symptoms, how have they changed?
When answering, think about all your symptoms combined.
Would you say:
- Improved
- Worsened
- Stayed the same
Post COVID-19 condition (long COVID) – self-identification
Some people may experience persistent, recurring, or new symptoms months after they thought or knew they had COVID-19. This is called post COVID-19 condition or long COVID when symptoms continue 3 or more months after the infection and cannot be explained by anything else.
Post COVID-19 condition is not COVID-19. Symptoms can be different from those experienced during the initial infection. Post COVID-19 condition refers to the longer-term effects some people experience after their COVID-19 infection.
Since the start of the COVID-19 pandemic, did you at any time experience post COVID-19 condition, also known as long COVID?
Since the start of the COVID-19 pandemic, has a healthcare provider ever told you that you have or might have post COVID-19 condition (long COVID)?
Labour market activities
Many of the following questions concern [your/FirstName's] activities last week.
Last week is from [OneWeekAgo] to [Yesterday].
Last week, did [you/FirstName] work at a job or business?
Select "Yes" if [you/he/she] worked at least one hour:
- for pay (wages, salary, etc.)
- in self-employment.
Select "No" if [you/he/she]:
- [were/was] away from work for the entire week for a reason such as vacation, illness, work schedule or layoff
- did not have a job or business but [were/was] able to work.
Select "Permanently unable to work" if [you/he/she]:
- did not have a job or business because of a physical or mental health condition that prevents [you/him/her] from working.
- Yes
- No
- Permanently unable to work
Last week, did [you/FirstName]have a job or business from which [you were] [he/she was] absent?
Select "Yes" if [you/he/she]:
- [were/was] away from work for the entire week for a reason such as vacation, illness, parental leave or work schedule
- [were/was] self-employed with a business, but no work was available.
Select "No" if [you/he/she]:
- did not have a job or business
- had a casual job, but no work was available.
What was the main reason [you were] [FirstName was] absent from work last week?
- Vacation
- Own illness or disability
- Caring for own children
- Caring for elder relative
60 years of age or older
- Maternity or parental leave
- Other personal or family responsibilities
- Labour dispute (strike or lockout)
Employees only
- Temporary layoff due to business conditions
Employees only
- Seasonal layoff
Employees only
- Casual job, no work available
Employees only
- Work schedule
e.g., 10 days on, 10 days off, employees only
- Self-employed, no work available
Self-employed only
- Seasonal business
Excluding employees
- Other, specify
- Specify the main reason [you/he/she] [were/was] absent from work last week
[Were you] [Was FirstName] an employee or self-employed?
Select "Employee" if [you/he/she] worked:
- for pay (wages, salary, tips or commissions).
Select "Self-employed" if [you/he/she] worked:
- for [your/his/her] own business, farm or professional practice
- as an independent contractor, painter, babysitter, etc.
- Employee
- Self-employed
- Working in a family business without pay
What was the full name of [your/FirstName's] business?
Enter the full name of the business. If there is no business name, enter the respondent's full name.
- Specify the full name of [your/his/her] business
For whom did [you/FirstName] work?
Enter the full name of the company, business, government department or agency, or person.
- Specify who [you/he/she] worked for
What kind of business, industry or service was this?
Examples: new home construction, primary school, municipal police, wheat farm, retail shoe store, food wholesale, car parts factory, federal government
- Specify the kind of business, industry or service
The following questions refer to the work or occupation in which [you/FirstName] spent most of [your/his/her] time.
What kind of work [were you] [was FirstName] doing?
Examples: legal secretary, plumber, fishing guide, wood furniture assembler, secondary school teacher, computer programmer
- Specify the kind of work [you/FirstName ] [were/was] doing
What were [your/FirstName's] most important activities or duties?
Examples: prepared legal documents, installed residential plumbing, guided fishing parties, made wood furniture products, taught mathematics, developed software
- Specify [your/his/her] most important activities or duties
[Excluding overtime, on average, how many paid hours [do you] [does FirstName] usually work per week?/On average, how many hours [do you] [does FirstName] usually work per week?]
If necessary, enter a decimal value e.g., 32.5.
Did [you/FirstName] have more than one job or business last week?
On average, how many hours [do you] [does he/she] usually work per week at [your/his/her] other job or jobs?
If necessary, enter a decimal value e.g., 32.5.
Telework
At the present time, in which of the following locations [do you] [does FirstName] usually work as part of [your/his/her] main job or business?
Select all that apply.
- At a fixed location outside the home
- Outside the home with no fixed location
e.g., driving, door-to-door sales
- At home
Include farms and all work done at the same address as [your/his/her] home, but on a different part of the property.
Last week, what proportion of [your/his/her] work hours did [you/FirstName] work at home as part of [your/his/her] main job or business?
Include farms and all work done at the same address as [your/his/her] home, but on a different part of the property.
- All [your/his/her] hours at home
- More than half, but not all [your/his/her] hours at home
- One quarter to half at home
- Less than a quarter at home
- No hours at home
Loss of productivity
At any time during the past three months, did you work at a job or a business?
Include only paid job or business.
What is the main reason that you have not worked at a job or business in the past three months?
Is it:
- Chronic physical or mental health condition diagnosed by a health professional
- Injury
e.g., broken bone, bad cut, burn and sprain
- Acute infectious disease
e.g., cold, flu and stomach flu
- Acute physical condition
Non-infectious
- Acute mental health condition
e.g., acute stress reaction
- Caring for own children
- Caring for elderly relatives (60 years or older)
- Maternity, paternity or parental leave
- Education, training or school
- Temporary lay-off
- Permanent lay-off
- Strike or lockout
- Retired
- Other
The next questions are about absence from work because of your own health.
Please include consultations with health professionals, but exclude absences because of the health of another person.
If you work part-time or at your own business, think only of the days you should have been working.
In the past three months, that is from [Date3MonthsAgo] to yesterday, have you missed any days at work because of a chronic health condition?
By this, we mean a long-term physical or mental health condition diagnosed by a health professional that has lasted or is expected to last 6 months or more.
In the past three months, how many days of work have you missed because of a chronic condition?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
Which chronic condition was this?
If you have more than one chronic condition, select the one which resulted in the most days of absence from work.
Was it:
- Arthritis
e.g., rheumatoid arthritis, osteoarthritis, lupus and gout
- Osteoporosis
- Cardiovascular disease
e.g., stroke and hypertension
- Kidney disease
- Asthma
- Chronic bronchitis, emphysema or chronic obstructive pulmonary disease (COPD)
- Diabetes
- Migraines
- Back problems
- Cancer
- Mental health conditions
e.g., depression, bipolar disorder, mania, and schizophrenia
- Neurological conditions
e.g., Alzheimer's disease, dementia, Parkinson's disease, multiple sclerosis, epilepsy, and cerebral palsy
Exclude spina bifida.
- Congenital anomalies, chromosomal abnormalities and malformations of the heart or digestive system
e.g., spina bifida, Down syndrome or trisomy 21
- Digestive diseases
e.g., Crohn's disease, celiac disease, irritable bowel syndrome, and stomach ulcers
- Infectious disease
e.g., HIV, tuberculosis, and hepatitis B and C
- Urinary incontinence
- Eye and ear diseases
e.g., glaucoma
- Skin diseases
e.g., psoriasis
- Fibromyalgia, chronic fatigue syndrome or multiple chemical sensitivities
- Other
- Specify the type of condition
In the past three months, have you missed any days at work because of an injury such as a broken bone, a bad cut, a burn or a sprain?
In the past three months, how many days of work have you missed because of an injury?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
The next questions are about acute health conditions, which are diagnosed or undiagnosed short-term physical or mental health conditions that last less than 6 months.
In the past three months, have you missed any days at work because of an acute infectious disease such as a cold, a flu, another respiratory infection or a stomach flu?
Which infectious diseases caused you to miss work in the past three months?
Select all that apply.
Was it:
- Cold
- Flu or influenza
- COVID-19
- Other respiratory infection
- Stomach flu
- Any other acute infectious disease
How many days of work have you missed because of a cold?
Symptoms of a cold include a runny nose, congestion and a cough.
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
How many days of work have you missed because of a flu or influenza?
Symptoms of influenza include fever, headache and body aches.
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
How many days of work have you missed because of COVID-19?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
How many days of work have you missed because of another respiratory infection such as pneumonia or acute bronchitis?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
How many days of work have you missed because of a stomach flu?
Symptoms of stomach flu include nausea, vomiting, stomach cramps and diarrhea.
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
How many days of work have you missed because of any other acute infectious disease?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
In the past three months, have you been absent from work because of any other acute, non-infectious physical condition?
e.g., migraine headache or bad back
How many days of work have you missed because of any other acute physical condition?
e.g., migraine headache or bad back
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
In the past three months, have you been absent from work because of an acute mental health condition?
e.g., acute stress reaction
How many days of work have you missed because of an acute mental health condition?
Exclude days for which time has been made up. If less than one day was missed, then enter one day.
Work family balance
For the next questions, please rate how much you agree with the following statements about conflict between your work and family lives.
a. The demands of my work interfere with my home and family life.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
b. The amount of time my job takes up makes it difficult to fulfill family responsibilities.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
c. Things I want to do at home do not get done because of the demands my job puts on me.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
d. Due to work-related duties, I have to make changes to my plans for family activities.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
e. My job produces strain that makes it difficult to fulfill family duties.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
f. The demands of my family or partner interfere with work-related activities.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
g. I have to put off doing things at work because of demands on my time at home.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
h. Things I want to do at work don't get done because of the demands of my family or partner.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
i. My home life interferes with my responsibilities at work such as getting to work on time, accomplishing daily tasks, and working.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
j. Family-related strain interferes with my ability to perform job-related duties.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
For the next questions, please rate how much you agree with the following statements about the effects of your involvement in your work.
a. My involvement in my work helps me to understand different viewpoints and this helps me be a better family member.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
b. My involvement in my work puts me in a good mood and this helps me be a better family member.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
c. My involvement in my work helps me feel personally fulfilled and this helps me be a better family member.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
For the next questions, please rate how much you agree with the following statements about the effects of your involvement with your family.
a. My involvement in my family helps me acquire skills and this helps me be a better worker.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
b. My involvement in my family puts me in a good mood and this helps me be a better worker.
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
c. My involvement in my family encourages me to use my work time in a focused manner and this helps me be a better worker.
-
- Strongly agree
- Agree
- Neither agree nor disagree
- Disagree
- Strongly disagree
Place of birth, immigration and citizenship
Where [were you] [was FirstName] born?
Specify place of birth according to present boundaries.
- Born in Canada
- Specify the province or territory
- Alberta
- British Columbia
- Manitoba
- New Brunswick
- Newfoundland and Labrador
- Northwest Territories
- Nova Scotia
- Nunavut
- Ontario
- Prince Edward Island
- Quebec
- Saskatchewan
- Yukon
- Born outside Canada
- Select the country
(dropdown list of countries in alphabetical order)
In what year did [you/FirstName] first come to Canada to live?
If exact year is not known, enter best estimate.
[Are you] [Is FirstName] now, or [have you] [has FirstName] ever been a landed immigrant?
A "landed immigrant" (permanent resident) is a person who has been granted the right to live in Canada permanently by immigration authorities.
In what year did [you/FirstName] first become a landed immigrant?
If exact year is not known, enter best estimate.
Of what country [are you] [is FirstName] a citizen?
Select all that apply.
[Are you] [Is FirstName] a citizen of:
- Canada
- Is it:
- By birth
- By naturalization
i.e., the process by which an immigrant is granted citizenship of Canada, under the Citizenship Act.
- Another country
- Select the country
(dropdown list of countries in alphabetical order)
Indigenous identity
[Are you] [Is FirstName] First Nations, Métis or Inuk (Inuit)?
First Nations (North American Indian) includes Status and Non-Status Indians.
- No, not First Nations, Métis or Inuk (Inuit)
OR
- Yes, First Nations (North American Indian)
- Yes, Métis
- Yes, Inuk (Inuit)
Sociodemographic characteristics
The following question collects information in accordance with the Employment Equity Act and its Regulations and Guidelines to support programs that promote equal opportunity for everyone to share in the social, cultural, and economic life of Canada.
Select all that apply.
[Are you] [Is he/she]:
- White
- South Asian
e.g., East Indian, Pakistani, Sri Lankan
- Chinese
- Black
- Filipino
- Arab
- Latin American
- Southeast Asian
e.g., Vietnamese, Cambodian, Laotian, Thai
- West Asian
e.g., Iranian, Afghan
- Korean
- Japanese
- Other
Language
Can [you/FirstName] speak English or French well enough to conduct a conversation?
- English only
- French only
- Both English and French
- Neither English nor French
What language [do you] [does FirstName] speak most often at home?
Select all that apply.
What is the language that [you/FirstName] first learned at home in childhood and still understand[s]?
If [you/FirstName] no longer understand[s] the first language learned, indicate the second language learned.
Select all that apply.
Sexual orientation
This question collects information on sexual orientation to inform programs that promote equal opportunity for everyone living in Canada to share in its social, cultural, and economic life.
What is your sexual orientation?
Sexual orientation refers to how a person describes their sexuality.
Would you say:
- Heterosexual
i.e., straight
- Lesbian or gay
- Bisexual or pansexual
- Or please specify
- Specify your sexual orientation
Sexual behaviour
Now a question about sexual activity. The information gathered will be helpful in distinguishing groups at risk for adverse health outcomes such as sexually transmitted and blood-borne infections (STBBIs) like human immunodeficiency virus (HIV) and hepatitis C virus (HCV). This information can be used to determine populations at higher risk for these adverse health outcomes, allowing for more targeted approaches that increase access to prevention, treatment, and care programs for these populations.
In the past 12 months, have you had sex?
Include vaginal and anal sex.
In the past 12 months, who have you had sex with?
Respond based on the sex assigned at birth of your sexual partners.
Include vaginal and anal sex.
Select all that apply.
Home care services
Now some questions on home care services that [you/FirstName] or anyone in the household may have received because of a health condition or a limitation in daily activities.
In the past 12 months, what type of home care services have been received?
Include services provided at home such as nursing care, meal preparation, someone to help with bathing or housework, etc.
Exclude post-partum care, help from family, friends or neighbours.
Select all that apply.
Was it:
- Nursing care
e.g., dressing changes, preparing medications
- Other health care services
e.g., physiotherapy, occupational or speech therapy, nutrition counselling
- Medical equipment or supplies
e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment
- Personal or home support
e.g., bathing, housekeeping, meal preparation
- Palliative or end-of-life care
- Other services
e.g., transportation, meals-on-wheels
OR
- No one in the household received any home care services
Who received these home care services?
a. Nursing care
e.g., dressing changes, preparing medications
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
b. Other health care services
e.g., physiotherapy, occupational or speech therapy, nutrition counselling
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
c. Medical equipment or supplies
e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
d. Personal or home support
e.g., bathing, housekeeping, meal preparation
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
e. Palliative or end-of-life care
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
f. Other services
e.g., transportation, meals-on-wheels
- [You/FirstName]
- Another member of the household
- [You/FirstName] and another member of the household
How long were home care services received?
If more than one household member is receiving a service, choose the longest period of time for which the service was provided.
a. Nursing care
e.g., dressing changes, preparing medications
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
b. Other health care services
e.g., physiotherapy, occupational or speech therapy, nutrition counselling
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
c. Medical equipment or supplies
e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
d. Personal or home support
e.g., bathing, housekeeping, meal preparation
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
e. Palliative or end-of-life care
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
f. Other services
e.g., transportation, meals-on-wheels
Time Period
- Less than 1 month
- 1 month to less than 3 months
- 3 months to less than 6 months
- 6 months to less than 1 year
- 1 year to 3 years
- More than 3 years
In a typical month over the past 12 months, how much was paid for home care services?
If more than one household member is receiving a service, choose the highest cost paid for the service.
a. Nursing care
e.g., dressing changes, preparing medications
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
b. Other health care services
e.g., physiotherapy, occupational or speech therapy, nutrition counselling
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
c. Medical equipment or supplies
e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
d. Personal or home support
e.g., bathing, housekeeping, meal preparation
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
e. Palliative or end-of-life care
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
f. Other services
e.g., transportation, meals-on-wheels
Cost
- $0
- $1 to less than $50
- $50 to less than $100
- $100 to less than $200
- $200 to less than $300
- $300 to less than $400
- $400 to less than $1,000
- $1,000 and more
Who paid for these services?
Select all that apply.
Was it:
- Out of [your/his/her] own pocket
- Family or friend living in the same household
- Someone living outside the household
e.g., family, friends, volunteer organization
- Insurance
- Government
- Other
Overall, what was the level of satisfaction for the home care services received?
Would you say:
- Very satisfied
- Somewhat satisfied
- Neither satisfied nor dissatisfied
- Somewhat dissatisfied
- Very dissatisfied
What are the reasons for the dissatisfaction?
Select all that apply.
- Poor quality
i.e., concerns about provider competence, reliability of services, etc.
- Services did not address perceived needs
- Services provided were insufficient
- Long wait times to receive services
- Other reason
Thinking of the home care services received in the past 12 months, how helpful were they in allowing the person or persons receiving these services to stay at home?
By "stay at home" we mean that it enabled the person to stay out of a hospital, nursing home, hospice, or assisted living facility.
Would you say:
- Very helpful
- Somewhat helpful
- Not helpful
- Reason for homecare was unrelated to staying at home
e.g., wound care
Why weren't the home care services helpful in allowing the person or persons receiving these services to stay at home?
Select all that apply.
- Poor quality
i.e., concerns about provider competence, reliability of services, etc.
- Services did not address perceived needs
- Services provided were insufficient
e.g., coverage, frequency, etc.
- Long wait times to receive services
- Cost of services was too high
- Other reason
During the past 12 months, was there ever a time when [you/FirstName] or anyone in the household felt that home care services were needed but were not received?
Were these home care services needed for [yourself/himself/herself] or someone else living in the household?
- [You/FirstName] only
- Other household member
- [You/FirstName] and other household member
[For the following questions, please only report for the home care services [you/FirstName] personally needed.]
Thinking of the most recent time, what type of home care was needed?
Select all that apply.
Was it:
- Nursing care
e.g., dressing changes, preparing medications
- Other health care services
e.g., physiotherapy, occupational or speech therapy, nutrition counselling
- Medical equipment or supplies
e.g., wheelchair, pads for incontinence, help with using a ventilator or oxygen equipment
- Personal or home support
e.g., bathing, housekeeping, meal preparation
- Palliative or end-of-life care
- Other services
e.g., transportation, meals-on-wheels
Again, thinking of the most recent time, why didn't [you/FirstName] or another member of the household get these services?
Select all that apply.
Was it:
- Not available in the area
- Not available at time required
e.g., inconvenient hours
- Waiting time too long
- Cost
- Didn't get around to it or didn't bother
- Didn't know where to go or call
- Language barrier
- Decided not to seek services
- Doctor did not think it was necessary
- Not eligible for home care
- Still waiting for home care
- Other
Where did [you/FirstName] or another member of the household try to get these home care services?
Select all that apply.
Was it:
- A government Home Care Program
e.g., CLSC in Quebec, CCAC in Ontario, Extramural Program in New Brunswick
- A private agency
- A family member, friend or neighbour
- A volunteer organization
- Other
OR
- Nowhere – did not try to get service
Health insurance coverage
Now, turning to [your/FirstName's] health insurance coverage. Please include any private, government or employer-paid plans.
[Do you] [Does he/she] have insurance that covers all or part of the cost of [your/his/her] prescription medications?
Include coverage from [your/his/her] own plan or someone else's
e.g., private, government, Non-Insured Health Benefits (NIHB), employer-paid plans
- Yes
Is it:
- A government sponsored plan
- An employer sponsored benefit plan
- A plan sponsored through an association such as a union, trade association or student organization
- Other, such as [your/his/her] own private plan purchased from an insurance company
- No
[Do you] [Does he/she] have insurance that covers all or part of [your/his/her] long-term care costs, including home care?
Include coverage from [your/his/her] own plan or someone else's
e.g., private, government, Non-Insured Health Benefits (NIHB), employer-paid plans
- Yes
Is it:
- A government sponsored plan
- An employer sponsored benefit plan
- A plan sponsored through an association such as a union, trade association or student organization
- Other, such as [your/his/her] own private plan purchased from an insurance company
- No
- Don't know
Insurance coverage
[Do you] [Does FirstName] have insurance that covers all or part of the cost of [your/his/her] long-term care, including home care?
Include coverage from [your/his/her] own plan or someone else's.
e.g., private, government, Non-Insured Health Benefits (NIHB), employer-paid plans
Prescription cost
In the past 12 months, did [you/FirstName] have any prescriptions for medication?
Include prescriptions received from a doctor but that were not filled.
In the past 12 months, did [you/FirstName] do any of the following because of the cost of [your/his/her] prescriptions?
Select all that apply.
Was it:
- Not fill a prescription
- Not collect a prescription
- Skip doses of [your/his/her] medicine
- Reduce the dosage of [your/his/her] medication
- Delay filling a prescription
OR
Food security
The following statements may describe the food situation for your household in the past 12 months. Please indicate if the statement was often true, sometimes true or never true for [you/you and other household members] in the past 12 months.
a. [You/You and other household members] worried that food would run out before you got money to buy more.
- Often true
- Sometimes true
- Never true
b. The food that [you/you and other household members] bought just didn't last and there wasn't any money to get more.
- Often true
- Sometimes true
- Never true
c. [You/You and other household members] couldn't afford to eat balanced meals.
- Often true
- Sometimes true
- Never true
d. [You/You or other adults in your household] relied on only a few kinds of low-cost food to feed [your child/the children] because you were running out of money to buy food.
- Often true
- Sometimes true
- Never true
e. [You/You or other adults in your household] couldn't feed [your child/the children] a balanced meal because you couldn't afford it.
- Often true
- Sometimes true
- Never true
[Your child was/The children were] not eating enough because [you/you or other adults in your household] just couldn't afford enough food.
Would you say:
- Often true
- Sometimes true
- Never true
[The following few questions are about the food situation in the past 12 months for you or any other adults in your household.]
In the past 12 months, since last [SurveyMonth] did you [or other adults in your household] ever cut the size of your meals or skip meals because there wasn't enough money for food?
How often did this happen?
Was it:
- Almost every month
- Some months but not every month
- Only 1 or 2 months
In the past 12 months, did you personally ever eat less than you felt you should because there wasn't enough money to buy food?
In the past 12 months, were you personally ever hungry but didn't eat because you couldn't afford enough food?
In the past 12 months, did you personally ever lose weight because you didn't have enough money for food?
In the past 12 months, did you [or other adults in your household] ever not eat for a whole day because there wasn't enough money for food?
How often did this happen?
Was it:
- Almost every month
- Some months but not every month
- Only 1 or 2 months
Now, a few questions on the food experiences for children in your household.
In the past 12 months, did you [or other adults in your household] ever cut the size of [your child's/any of the children's] meals because there wasn't enough money for food?
In the past 12 months, did [your child/any of the children] ever skip meals because there wasn't enough money for food?
How often did this happen?
Was it:
- Almost every month
- Some months but not every month
- Only 1 or 2 months
In the past 12 months, [was your child/were any of the children] ever hungry but you couldn't afford more food?
In the past 12 months, did [your child/any of the children] ever not eat for a whole day because there wasn't enough money for food?
Administrative information
To enhance the data from this survey and to minimize the reporting burden for respondents, Statistics Canada will combine [your/FirstName's] responses with information from the tax data of all members of your household. [Statistics Canada, the provincial ministry of health and the Institut de la statistique du Québec/Statistics Canada and the territorial ministry of health/Statistics Canada and the provincial ministry of health] may also add information from other surveys or administrative sources.
Having a provincial or territorial health number will assist us in linking to this other information. [Do you] [Does FirstName] have [a provincial or territorial] health number?
For which province or territory is [your/FirstName's] health number?
If [you do/FirstName does] not have a Canadian health number, select "No Canadian health number" from the drop down.
Province or territory
- Alberta
- British Columbia
- Manitoba
- New Brunswick
- Newfoundland and Labrador
- Northwest Territories
- Nova Scotia
- Nunavut
- Ontario
- Prince Edward Island
- Quebec
- Saskatchewan
- Yukon
- No Canadian health number
What is [your/FirstName's] health number?
Enter a health number for [Province or Territory]. In [Province or Territory] the health number is made up of [Province or Territory number format]. Do not insert blanks, hyphens or commas between the numbers.
[Note: In Manitoba, health numbers of families can be listed on the same card. Be sure to capture the intended respondent's health number if there is more than one on the card.]
[Note: In British Columbia, residents may have a combined driver's license and health card. If the respondent has a combined card, the health number is on the back above the barcode.]
[To avoid duplication of surveys, Statistics Canada has signed agreements to share the data from this survey with provincial and territorial ministries of health. Provincial ministries of health may make the data available to local health authorities.
Data shared with [your/his/her] ministry of health may also include identifiers such as name, address, telephone number and health card number. Local health authorities would receive only survey responses and the postal code.]
[To avoid duplication of surveys, Statistics Canada has signed agreements to share the data from this survey with provincial and territorial ministries of health, and the Institut de la statistique du Québec. The Institut de la statistique du Québec and provincial ministries of health may make this data available to local health authorities.
Data shared with [your/his/her] ministry of health or the Institut de la statistique du Québec may also include identifiers such as name, address, telephone number and health card number. Local health authorities, would receive only survey responses and the postal code.]
These organizations have agreed to keep the data confidential and use it only for statistical purposes.
[Do you] [Does FirstName] agree to share the data provided?
To reduce the number of questions in this questionnaire, Statistics Canada will use information from [your/FirstName's] tax forms submitted to the Canada Revenue Agency. With [your/his/her] consent Statistics Canada will share this information from [your/his/her] tax forms with [provincial and territorial ministries of health and the Institut de la statistique du Québec/provincial and territorial ministries of health]. These organizations have agreed to keep the information confidential and to use it only for statistical and research purposes.
[Do you] [Does FirstName] give Statistics Canada permission to share [your/his/her] tax information with [provincial and territorial ministries of health and the Institut de la statistique du Québec/provincial and territorial ministries of health]?
