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Self 2003
Medical Expenditure Panel Survey
A Survey About Your Diabetes Care
The care of people with diabetes is an important concern ofthe 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. Ifyou 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 completedthe survey, please fold it,seal it with this
label, andplace it in the envelope provided.
The Agency for Healthcare Research and Quality andThe National Center
for Health Statistics of the U.S.Public Health Service
OMB # 0935-0104
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.
1. Have you ever been told by a doctor or other health professional that
you have diabetes or sugar diabetes? (CHECK ONE)
Yes......................................Please continue.
No......................................Thank you for your time. This
survey is complete.
2. During 2002, 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)
Number of Times ......................
Never........................................
Don't know................................
3. During 2002, how many times did a health professional check your
feet for any sores or irritations? (FILL IN NUMBER OF TIMES)
Number of Times ......................
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. (CHECK ALL THATAPPLY)
During 2003 ..............................
During 2002 ..............................
During 2001 ..............................
Before 2001 ..............................
Never........................................
5. Has your diabetes caused problems with your kidneys?
Yes ............................................
No..............................................
6. Has your diabetes caused problems with your eyes that needed to be
treated by an ophthalmologist?
Yes ............................................
No..............................................
7. Is your diabetes being treated by modifying your diet?
Yes ............................................
No..............................................
8. Is your diabetes being treated by medications taken by mouth?
Yes ............................................
No..............................................
9. Is your diabetes being treated with insulin injections?
Yes ............................................
No..............................................
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.
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?___________________________________________________________________________________________________________________
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 Statutes, Section 924(c)
and Section 308(d) of the Public Health Service Act [42 U.S.C.299c-3(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-B200
Independence Avenue, SW
Washington, DC 20201
OMB # 0935-0104
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