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Proxy 2007
MEPS
Medical Expenditure Panel Survey
A Survey About Diabetes Care
The care of people with diabetes is an important concern of the Public
Health Service. We would appreciate it if you would take a few minutes
to answer the following questions on the care your family member received
for his or her diabetes. Your participation is voluntary and all of the 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 for
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.
The Agency for Healthcare Research and Quality and
The Centers for Disease Control and Prevention 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. In the questions below, “(NAME)” refers
to the person listed in the box on the front page.
1. Has (NAME) ever been told by a doctor or other health professional
that he/she has diabetes or sugar diabetes? (CHECK ONE)
Yes ............................................ Please continue.
No..............................................Thank you for your
time.
This survey is complete.
2. During 2006, how many times did a doctor, nurse, or other health
professional check (NAME)’s blood for
glycosylated hemoglobin or “hemoglobin
A-one-C”? (FILL IN NUMBER OF TIMES)
Number of Times ...................... ____
Did not have a blood test ..........
Don't know ................................
Never ........................................
3. During 2006, how many times did a
health professional check (NAME)’s feet
for any sores or irritations? (FILL IN NUMBER
OF TIMES)
Number of Times ...................... ____
Never ........................................
4. Which of the following year(s) did (NAME)
have an eye exam in which his/her pupils
were dilated? This would have made
him/her temporarily sensitive to bright
light. (CHECK ALL THAT APPLY)
During 2007 ..............................
During 2006 ..............................
During 2005 ..............................
Before 2005 ..............................
Never ........................................
5. Has (NAME)’s diabetes caused problems
with his/her kidneys?
Yes ............................................
No..............................................
6. Has (NAME)’s diabetes caused problems
with his/her eyes that needed to be
treated by an ophthalmologist?
Yes ............................................
No..............................................
7. Is (NAME)’s diabetes being treated by
modifying his/her diet?
Yes ............................................
No..............................................
8. Is (NAME)’s diabetes being treated by
medications taken by mouth?
Yes ............................................
No..............................................
9. Is (NAME)’s diabetes being treated with
insulin injections?
Yes ............................................
No..............................................
10. During the last 6 months, has (NAME)
received any of the following to teach
him/her how to take care of his/her
diabetes:
Telephone call to his/her house
Yes ............................................
No..............................................
Appointment with nurse
Yes ............................................
No..............................................
Visit to his/her home
Yes ............................................
No..............................................
Referral to a specialist
Yes ............................................
No..............................................
11. About how long has it been since (NAME)
had his/her blood cholesterol checked by
a doctor or other health professional?
WITHIN PAST YEAR ....................
WITHIN PAST 2 YEARS ................
WITHIN PAST 3 YEARS ................
WITHIN PAST 5 YEARS ................
MORE THAN 5 YEARS ................
NEVER ........................................
12. About how long has it been since (NAME)
had a flu shot?
WITHIN PAST YEAR ....................
WITHIN PAST 2 YEARS ................
WITHIN PAST 3 YEARS ................
WITHIN PAST 5 YEARS ................
MORE THAN 5 YEARS ................
NEVER ........................................
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
Who completed the survey for the person named on the front page?
What is your relationship to the person named on the front page?
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-B
200 Independence Avenue, SW
Washington, DC 20201
21056.1006.76902505
Data Year 2006
07-231
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