Form Approved
OMB# 0935-0118
Exp. Date 01/31/2013
2012
Your Health and Health Opinions
Your Opinion Matters!
Medical Expenditure Panel Survey (MEPS)
Understanding how people feel about their health and health care is an
important goal of MEPS. Please take a few minutes to answer the questions
in this booklet.
Survey Instructions
- Please answer every question by checking one box
“.” If you are unsure about how to answer a question, please give the best answer you can.
- You are sometimes told to skip over some questions in this survey. When this happens you will be told what questions to answer next, otherwise,
go to the next question.
This Booklet Should
Be Completed By |
RUID: |
_______________ |
PID: |
_________________ |
Name: |
____________________________________________ |
Version: |
__________ |
DOB: |
__________ |
Panel/ Round: |
__________ |
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Your participation is voluntary and all of your answers will be kept confidential to the extent permitted by law. If you have any questions about this booklet, please call Alex Scott at 1-800-945-MEPS (6377).
When you have completed the booklet, please seal it with this label and place it in the
envelope provided. Have it ready to give to your interviewer at his or her next visit.
Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that
information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it
was supplied unless you consent to the use of the information for another purpose. Public reporting burden for this collection of information is estimated
to average 7 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate
or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA,
Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.
|
The Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention of the
U.S. Department of Health and Human Services |
Start Here
Your Health Care in the Last 12 Months
1. |
In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor's office? |
1 |
Yes |
2 |
No Skip to Question 3 |
3. |
In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic? |
1 |
Yes |
2 |
No Skip to Question 5 |
6. |
In the last 12 months, did you or a doctor believe you needed any care, tests, or treatment? |
1 |
Yes |
2 |
No Skip to Question 8 |
12. |
In the last 12 months, did a doctor or
other health provider give you instructions
about what to do about a specific illness or
health condition? |
1 |
Yes |
2 |
No Skip to Question 15 |
15. |
In the last 12 months, did you have to fill out or sign any forms at a doctor’s or other
health provider’s office? |
1 |
Yes |
2 |
No Skip to Question 17 |
18. |
Do you currently smoke? |
1 |
Yes |
2 |
No Skip to Question 20 |
20. |
In the last 2 years, has your blood
pressure been checked by a doctor,
nurse, or other health professional? |
1 |
Yes |
2 |
No |
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Getting Health Care from a Specialist
When you answer the next questions, do not include dental visits.
21. |
Specialists are doctors like surgeons, heart
doctors, allergy doctors, skin doctors, and
others who specialize in one area of
health care.
In the last 12 months, did you or a doctor
think you needed to see a specialist? |
1 |
Yes |
2 |
No Skip to Question 23 |
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General Health
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
During the past 4 weeks, how much of the time
have you had any of the following problems
with your work or other regular daily activities
as a result of your physical health?
During the past 4 weeks, how much of the
time have you had any of the following
problems with your work or other regular
daily activities as a result of any emotional
problems (such as feeling depressed or
anxious)?
These questions are about how you feel and
how things have been with you during the past
4 weeks. For each question, please give the one
answer that comes closest to the way you have
been feeling.
How much of the time during the past 4 weeks:
The following questions ask about how you have been feeling during the past 30 days. For each
question, please place a check mark in the box that best describes how often you had this feeling.
The following two questions ask about how you have been feeling in the past 2 weeks.
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Opinions about Health
For items 43-46, please check one of the boxes to indicate how strongly you agree or disagree for each statement. If you are uncertain, check the box for uncertain
(3).
Back to top
Date completed: _________________________________
If this booklet was not completed by the person named on the front, who completed it:
____________________________________________________________________________________
What is this person’s relationship to the person named on the front:
____________________________________________________________________________________
____________________________________________________________________________________
Thank you for taking the time to complete this survey.
Remember to seal it and place it in the envelope provided.
Publication 12-228
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