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The care of people with diabetes is an important
concern of the Public Health Service. 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. If you have any questions about this survey, please call
Alex Scott at 1-800-945-MEPS (6377).
This survey should
be completed by
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NAME:
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DOB: |
_____ |
PID: |
_____ |
| RUID: |
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When you have completed the survey, please fold it,
seal it with this label, and place it in the envelope provided.
The Agency for Healthcare Research and Quality and
The National Center for Health Statistics of the U.S. Public Health
Service. OMB # 0935-0104
A Survey About Your Diabetes Care
Instructions:
Answer every question by checking one box
or filling in a number as indicated. If you are unsure about how to answer
a question, please give the best answer you can.
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1.
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Have you ever been told by a doctor or
other health professional that you have diabetes or sugar
diabetes? (CHECK ONE)
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Yes
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 1
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Please continue.
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No
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2
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Thank you for your time.
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This survey is
complete.
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2.
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During 2000, how many times did a doctor,
nurse, or other health professional check you for glycosylated hemoglobin
or "hemoglobin A-one-C"?
(FILL IN NUMBER OF TIMES)
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Number of Times
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____
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Never
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96
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Don't Know
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98
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3.
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During 2000, how many times did a health
professional check your feet for any sores or irritations?
(FILL IN NUMBER OF TIMES)
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Number of Times
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____
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Never
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96
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4.
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When was the last time you had an eye exam
in which your pupils were dilated? This would have made you temporarily
sensitive to bright light.
(CHECK ONE)
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During 2001
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1
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During 2000
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2
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During 1999
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3
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Before 1999
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4
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Never
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5
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5.
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Has your diabetes caused problems with
your kidneys?
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Yes
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1
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No
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2
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6.
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Has your diabetes caused problems with
your eyes that needed to be treated by an ophthalmologist?
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Yes
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1
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No
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2
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7.
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Is your diabetes being treated by
modifying your diet?
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Yes
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1
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No
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2
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8.
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Is your diabetes being treated by
medications taken by mouth?
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Yes
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1
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No
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2
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9.
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Is your diabetes being treated with
insulin injections?
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Yes
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1
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No
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2
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Thank you for taking the time to
complete this important survey.
Please remember to fold it, seal it, and place it in the
envelope provided.
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?
What is the reason the person named on the front
page did not complete the survey himself/herself?
This survey is part of the Medical Expenditure
Panel Survey, conducted by the U.S. Public Health Service. This survey is
authorized under Section 902(a) of the Public Health Service Act [42 U.S.C.
299a]. The confidentiality of personal information is protected by Federal
statute, Section 903(c) and Section 308(d) of the Public Health Service
Act [42 U.S.C 299a - 1(c) and 242m(d)]. This law prohibits release of
personal information outside the public health agencies sponsoring the
survey or their contractors without first obtaining permission from the
person who gave the information. The Federal government requires that all
persons asked to respond to one of its surveys be given the following
information: Public reporting burden for this collection of information is
estimated to average 5 minutes per interview, the estimated time required
to complete the "A Survey About Your Diabetes Care." Send
comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden,
to:
Reports Clearance Officer Attention: PRA, United
States Public Health Service Paperwork Reduction Project (0935-0098)
Hubert H. Humphrey Building, Room 721-B 200 Independence Avenue, SW
Washington, DC 20201
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