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Medical Expenditure Panel Survey
Your Health & Health Opinions
Your opinion matters!
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.
This booklet should be completed by:
RUID: __________________ VERSION: ____________
NAME: ________________________________________
DOB: __________________ PID: ________________
The Agency for Healthcare Research and Quality and
The National Center for Health Statistics of the U.S. Public Health Service
OMB # 0935-0104
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.
Your participation is voluntary and all of your answers will be kept
confidential. 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 fold it, 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 HEALTH CARE IN THE LAST 12 MONTHS
1. A health provider 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.
In the last 12 months, did you make any appointments
with a doctor or other health provider for
regular or routine health care?
Yes ..............................................
No ..............................................GO TO
QUESTION 3
2. In the last 12 months, how often did you get an
appointment for regular or routine health care
as soon as you wanted?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I didn’t need an appointment for regular
or routine care in the last 12 months.......
3. In the last 12 months, did you have an illness or
injury that needed care right away from a doctor’s
office, clinic, or emergency room?
Yes ..............................................
No ..............................................GO TO
QUESTION 5
4. In the last 12 months, when you needed care right
away for an illness or injury, how often did you get
care as soon as you wanted?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I didn’t need care right away for an
illness or injury in the last 12 months.....
5. In the last 12 months (not counting times you went
to an emergency room), how many times did you go
to a doctor’s office or clinic to get care for yourself?
None ..........................................GO TOQUESTION 11
1 ..............................................................
2 ..............................................................
3 ..............................................................
4 ..............................................................
5 to 9 ......................................................
10 or more ..............................................
6. In the last 12 months, how much of a problem, if
any, was it to get the care you or a doctor believed
necessary?
A big problem..........................................
A small problem ......................................
Not a problem ........................................
I had no visits in the last 12 months......
7. In the last 12 months, how often did doctors or other
health providers listen carefully to you?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I had no visits in the last 12 months ......
8. In the last 12 months, how often did doctors or other
health providers explain things in a way you could
understand?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I had no visits in the last 12 months. ......
9. In the last 12 months, how often did doctors or other
health providers show respect for what you had
to say?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I had no visits in the last 12 months. ......
10. In the last 12 months, how often did doctors or other
health providers spend enough time with you?
Never ......................................................
Sometimes ..............................................
Usually ....................................................
Always......................................................
I had no visits in the last 12 months. ......
11. We want to know your rating of all your health care
in the last 12 months from all doctors and other
health providers.
Use any number from 0 to 10 where 0 is the worst
health care possible, and 10 is the best health care
possible. How would you rate all your health care?
0 Worst health care possible ..................
1 ..............................................................
2 ..............................................................
3 ..............................................................
4 ..............................................................
5 ..............................................................
6 ..............................................................
7 ..............................................................
8 ..............................................................
9 ..............................................................
10 Best health care possible ..................
I had no visits in the last 12 months. ......
12. In the last 2 years, has your blood pressure been
checked by a doctor, nurse, or other health
professional?
Yes ..............................................
No ..............................................
13. Do you currently smoke?
Yes ..............................................
No ..............................................GO TO
QUESTION 15
14. In the past 12 months did a doctor advise you to
quit smoking?
Yes ..............................................
No ..............................................
GETTING HEALTH CARE FROM A SPECIALIST
When you answer the next questions, do not include
dental visits.
15. 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?
Yes ..........................................
No .......................................... GO TO
QUESTION 17
16. In the last 12 months, how much of a problem, if
any, was it to get a referral to a specialist that you
need to see?
A big problem..........................................
A small problem ......................................
Not a problem ........................................
I didn’t need to see a specialist
in the last 12 months. ............................
GENERAL HEALTH
17. In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
18. The following items are about activities you might do during a typical
day. Does your health now limit you in
these activities? If so, how much?
A. Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or playing golf
Yes, Limited a lot
Yes, Limited a Little
No, Not Limited At All
B. Climbing several flights of stairs ................................................
Yes, Limited a lot
Yes, Limited a Little
No, Not Limited At All
19. During the past 4 weeks, have you had any of the following problems
with your work or other regular daily activities as a result of your
physical health?
A. Accomplished less than you would like ....................................................
Yes
No
B. Were limited in the kind of work or other activities..................................
Yes
No
20. During the past 4 weeks, 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)?
A. Accomplished less than you would like ....................................................
Yes
No
B. Didn’t do work or other activities as carefully as usual............................
Yes
No
21. During the past 4 weeks, how much did pain interfere with your normal
work (including both work outside the home and housework)?
Not At All
A Little Bit
Moderately
Quite a Bit
Extremely
22. 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 –
A. Have you felt calm and peaceful?..............................
All of the time
Most of the time
A good Bit of the Time
Some of the Time
A little of the Time
None of the Time
B. Did you have a lot of energy?....................................
All of the time
Most of the time
A good Bit of the Time
Some of the Time
A little of the Time
None of the Time
C. Have you felt downhearted and blue? ......................
All of the time
Most of the time
A good Bit of the Time
Some of the Time
A little of the Time
None of the Time
23. During the past 4 weeks, how much of the time has your physical
health or emotional problems interfered with your social activities (like
visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the Time
A little of the Time
None of the Time
OPINIONS ABOUT HEALTH
24. For each of the following statements, please check one of the boxes
to indicate how strongly you AGREE or DISAGREE with the statement.
A. I’m healthy enough that I really don’t need health insurance.....................
Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly
B. Health insurance is not worth the money it costs........
Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly
C. I’m more likely to take risks than the average person...
Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly
D. I can overcome illness without help from a medically trained person...............
Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly
DAILY ACTIVITIES
25. By placing a check in one box in each group below, please indicate
which statement best describes your own health state today.
A. Mobility
I have no problems in walking about.....
I have some problems in walking about...
I am confined to bed....................
B. Self-Care
I have no problems with self-care........
I have some problems washing or dressing myself....
I am unable to wash or dress myself.........
C. Usual Activities (e.g., work, study, housework, family or leisure
activities)
I have no problems with performing my usual activities....
I have some problems with performing my usual activities......
I am unable to perform my usual activities.......
D. Pain/Discomfort
I have no pain or discomfort........
I have moderate pain or discomfort.....
I have extreme pain or discomfort......
E. Anxiety/Depression
I am not anxious or depressed...........
I am moderately anxious or depressed......
I am extremely anxious or depressed.......
26. Compared with my general level of health over the past 12 months,
my health state today is:.......
Better
Much the Same
Worse
27. To help people say how good or bad a health state is, we have drawn
a scale (rather like a thermometer) on which the best state you can imagine
is marked by 100 and the worst state you can imagine is marked by 0.
We would like you to indicate on this scale how good or bad your own
health is today, in your opinion. Please do this by drawing a line from
the circle below to whichever point on the scale indicates how good or
bad your current health state is.
If this booklet was not completed by the person named on page 1, who
completed it:
What is this person’s relationship to the person named on page
1:
Thank you for taking the time to complete this survey.
Remember to fold it, seal it, and place it in the envelope provided.
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 Section308 (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 survey about
Your Health and Health Opinions. 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-B200
Independence Avenue, SW
Washington, DC 20201
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