Annual Canadian Community Health Survey

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.

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
- 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

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.

Male
Female

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.

Feet
Inches

Centimetres

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?

Age in years

How old [were/was] [you/he/she] when this was first diagnosed?

Age in years

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

None of the above

[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?

Age in years

[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?

Age in years

[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?

Age in years

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?

Age in years

How old [were/was] [you/he/she] when this was first diagnosed?

Age in years

How old [were/was] [you/FirstName] when the first symptoms of chronic fatigue syndrome (CFS) appeared?

Age in years

How old [were/was] [you/he/she] when this was first diagnosed?

Age in years

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

None of the above

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
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- 26
- 27
- 28
- 29
- 30
- 31
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- 33
- 34
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- 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.
- a.m.
- 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.
- a.m.
- 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.
- a.m.
- 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.
- a.m.
- p.m.

Overall, how would you rate [your/his/her] sleep quality over the past 7 days?

Would you say:

Excellent
Good
Fair
Poor

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

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

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
- Specify the activity

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
- Specify the location

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
- Specify the injuries

No injuries

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
- Specify the injury

[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
- Specify the location

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

None of these activities

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?

Age in years

[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?

Number of cigarettes

In the past 30 days, how many days [have you] [has he/she] smoked one or more cigarettes?

Number of days

On the days that [you/FirstName] [do/does] smoke, how many cigarettes [do/does] [you/he/she] usually smoke?

Number of cigarettes

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?

Age in years

When [you/FirstName] smoked every day, how many cigarettes did [you/he/she] usually smoke each day?

Number of cigarettes

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?

Plain
Flavoured
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?

Age in years

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

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

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

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?

Just once
More than once

At what age did you first try cannabis?

Age in years

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
- Specify other method

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
- Specify other product

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
- Specify other symptom

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?

Age in years

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
- Specify the effect

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
- Specify other place

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.

Online
In-person
Both

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?
  - 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]
  - First name
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.

Yes
No
Don't know

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.

Yes
No
Don't know

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.

Yes
No
Don't know

Just before your pregnancy with [BabyName/this child], how much did you weigh?

Weight
Pounds or kilograms
- Pounds
- 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
- Pounds
- 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
- Days
- Weeks
- Months
- Years

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
- Days
- Weeks
- Months
- Years

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.

Other

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
- Days
- Weeks
- Months
- Years

[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?

Yes
No
Don't know

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?

This year
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.

Yes
No
Don't know

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.

Yes
No
Don't know

[Do you][Does he/she] have to pay out-of-pocket for any of the services provided by the team of health professionals?

Yes
No
Don't know

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?

Yes
No
Don't know

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

Don't know

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

Don't know

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

None of the above

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:

Excellent
Good
Fair
Poor

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:

Excellent
Good
Fair
Poor

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
- Specify other reason

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
- Specify other reason

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

Number of times

b. Psychiatrist

Number of times

c. Psychologist

Number of times

d. Nurse

Number of times

e. Social worker or counsellor

Number of times

f. Other

Number of times

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.

Yes
No
Don't know

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?

Yes
No
Don't know

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

I received all the necessary dental care or treatment

Don't know

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

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

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.

Number of months

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.

Hours

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.

Hours

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Days of work missed

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.

Year of arrival

[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.

Year of immigration

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)

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
- Specify other group

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.

English
French
Other
- Specify other language

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.

English
French
Other
- Specify other language

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.

Male(s)
Female(s)

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

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

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

Yes
No
Don't know

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

None of the above

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.]

Health number

[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]?

Annual Canadian Community Health Survey – 2026

Getting started

Why are we conducting this survey?

Other important information

Authorization and confidentiality

Record linkages

Date of birth

Sex and gender

Marital status

Family relationships

Main activity

School attendance

General health

Life satisfaction measures

Sense of meaning and purpose

Future outlook

Mental health

Pregnancy

Height and weight

Multiple chemical sensitivities

Chronic pain

Chronic conditions

Chronic mental health and neurodevelopmental conditions

Abilities

Long-term conditions

Moderate physical activity

Sedentary behaviours

Activities of daily living

Canada's Food Guide use

Eating habits

Sleep quality

Injury and poisoning

Use of protective equipment

Current smoking status

Smoking – past use

Smoking – stages of change

Tobacco products alternatives

Electronic cigarettes and vaping

Cannabis use

Severity of dependence scale for cannabis

Alcohol use

Gambling

Parental experiences

Maternal experiences – alcohol use during pregnancy

Maternal experiences – smoking during pregnancy

Pap smear test

Mammography

Colorectal cancer testing

Flu shots

Vaccines

Regular health care provider

Electronic health information

Mental health

Suicide

Positive mental health

Social provisions

Sources of stress

Perceived need for care

Consultations on mental health

Oral health

COVID-19 – vaccination

COVID-19 – infections

COVID-19 – symptoms

Post COVID-19 condition (long COVID) – self-identification

Labour market activities

Telework

Loss of productivity

Work family balance

Place of birth, immigration and citizenship

Indigenous identity

Sociodemographic characteristics

Language

Sexual orientation

Sexual behaviour

Home care services

Health insurance coverage

Insurance coverage

Prescription cost

Food security

Administrative information