So here's the sample the authors give (pointing out that the instruction not to return the questionnaire to the interviewer is important & must be made clear):
For each one of the following statements give a score of 1 in the right column if the statement applies to you and a score of 0 if not. If a statement consists of two substatements, such as in Statement 2 or Statement 4, a score of 1 should be given if at least one of the substatements applies and a score of 0 if none of them does. Count the number of 1's put in the right column. This is your total score. Report the total score and nothing else. Do not return the questionnaire. It is given to you for your convenience. ["for your convenience"?? --Fflo]
Questionnaire 1
Statement Score
1 I have never been hospitalized
2 Substatement 2a: I do have hay fever
Substatement 2b: I do have eczema
3 I have taken antibiotics during the last two years
4 Substatement 4a: I make use of marijuana
Substatement 4b: During my childhood I did not have asthma
5 At least one of my parents was a smoker during my childhood
6 I consider smoking no less harmful than the use of marijuana
Total Score _______
Questionnaire 2
Statement Score
1 I have never been hospitalized
2 Substatement 2a: I do have hay fever
Substatement 2b: I do have eczema
3 I have taken antibiotics during the last two years
4 Substatement 4a: I do not make use of marijuana
Substatement 4b: During my childhood I did not have asthma
5 At least one of my parents was a smoker during my childhood
6 I consider smoking no less harmful than the use of marijuana
Total Score _______
