Form Approved
OMB #0935-0118
Expiration Date 11/30/2023

Self 2023

Medical Expenditure Panel Survey (MEPS)

A Survey About Your Diabetes Care

The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. Please take a few minutes to answer the following questions on the care you received for your diabetes. 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 survey, please call Alex Scott at 1-800-945-MEPS (6377).

This survey should be completed by

NAME:

DOB:   PID:

RUID:

When you have completed the survey, return it to your interviewer.

This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c). Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated t average 3 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, 5600 Fishers Lane Room #07W42, Rockville, MD 20857.

Department of Health and Human Services (DHHS)

The Agency for Healthcare Research and Quality of the
U.S. Department of Health and Human Services

A Survey About Your Diabetes Care

Instructions:  Answer each question by marking one box sample check box with check mark or filling in a number when necessary. If you are unsure about how to answer a question, please give the best answer you can.

A health professional could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.

1.
 Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes? MARK sample check box with check mark ONE.
  empty check box Yes Please continue. 
  empty check box No Thank you for your time. This survey is complete.

2.
 During 2022, how many times did a doctor, nurse, or other health professional check your blood for glycosylated hemoglobin or "hemoglobin A-one-C"? (A1C is a blood test to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor’s office although a home kit containing materials for one or two tests is now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis, and needs supplies of disposable test strips.)
    If you had this blood test, fill in NUMBER OF TIMES
  empty check box Did not have A1C blood test
  empty check box Don’t know
  empty check box Never

3.
 Which of the following year(s) did a doctor or other health professional check your feet for any sores or irritations? MARK sample check box with check mark ALL THAT APPLY.
  empty check box During 2023
  empty check box During 2022
  empty check box During 2021
  empty check box Before 2021
  empty check box Never

4.
 Which of the following year(s) did you have an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light. MARK sample check box with check mark ALL THAT APPLY.
  empty check box During 2023
  empty check box During 2022
  empty check box During 2021
  empty check box Before 2021
  empty check box Never

5.
 Which of the following year(s) did you have your blood cholesterol checked? MARK sample check box with check mark ALL THAT APPLY.
  empty check box During 2023
  empty check box During 2022
  empty check box During 2021
  empty check box Before 2021
  empty check box Never

6.
 Which of the following year(s) did you get a flu vaccination (shot or nasal spray)? MARK sample check box with check mark ALL THAT APPLY.
  empty check box During 2023
  empty check box During 2022
  empty check box During 2021
  empty check box Before 2021
  empty check box Never

7.
 Has your diabetes caused problems with your kidneys?
  empty check box Yes
  empty check box No

8.
 Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist?
  empty check box Yes
  empty check box No

9.
 Is your diabetes being treated by modifying your diet?
  empty check box Yes
  empty check box No

10.
 Is your diabetes being treated by medications taken by mouth?
  empty check box Yes
  empty check box No

11.
 Is your diabetes being treated with insulin injections?
  empty check box Yes
  empty check box No

12.
 During the last 12 months, have you learned how to take care of your diabetes?
arrow pointing to next question empty check box Yes
empty check box No Go to Question 14

13.
 Which of the following methods have you used to learn to take care of your diabetes? MARK sample check box with check mark ALL THAT APPLY.
  empty check box Talking to a doctor/health professional within your primary care practice
  empty check box Talking to a doctor/health professional not in your primary care practice
  empty check box Telephone call with a health professional
  empty check box Reading about it on the Internet
  empty check box Taking a group class
  empty check box Other (specify)

14.
 How confident are you in taking care of your diabetes?
  empty check box Not confident at all
  empty check box Somewhat confident
  empty check box Confident
  empty check box Very confident
  empty check box Refused
  empty check box Don’t know

Thank you for taking the time to complete this important survey.

Please remember to return it to your interviewer.

Date completed:

If this survey was not completed by the person named on the front page, who completed the survey?

What is this person’s relationship to the person named on the front page?
empty check box Husband or wife
empty check box Unmarried partner
empty check box Mother, father, or guardian
empty check box Son or daughter
empty check box Other relative
empty check box Not related

What is the reason the person named on the front page did not complete the survey himself/herself?

Data Year 2022
23-230

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