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Self 2005
MEPS
Medical Expenditure Panel Survey
A Survey About Your Diabetes Care
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
NAME: ________________________________
DOB:______________ PID:________________
RUID: ________________________________
When you have completed the survey, please fold it, seal it with this
label, and place it in the envelope provided.
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 2004, 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 2004, 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 THAT APPLY)
During 2005 ..............................
During 2004 ..............................
During 2003 ..............................
Before 2003 ..............................
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 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 Service 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 Statutes,
Attention: PRA, United States Public Health
Paperwork Reduction Project (0935-0098)
Hubert H. Humphrey Building, Room 721-B
200 Independence Avenue, SW
Washington, DC 20201
16356.1104.71502905
Data Year 2004
05-230
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