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Form Approved
OMB #0935-0118
Exp. Date 01/31/2013

Self 2011

Medical Expenditure Panel Survey (MEPS)

A Survey About Your Diabetes Care

The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. 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 to the extent permitted by law. 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.

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied unless you consent to the use of the information for another purpose. Public reporting burden for this collection of information is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-0118) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

The Agency for Healthcare Research and Quality and The Centers for Disease Control and Prevention of the U.S. Department of Health and Human Services. OMB # 0935-0118

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.

A health professional 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.

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 2010, how many times did a doctor, nurse, or other health professional check (NAME)’s blood for glycosylated hemoglobin or “hemoglobin A-one-C?” (A1C is a blood test to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor's office although a home kit containing materials for one or two tests in now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis, and need supplies of disposable test strips.)
	If you had this blood test, fill in NUMBER OF TIMES	_____
	Did not have A1C blood test
	Don't know
	Never

3.	Which of the following year(s) did a doctor or other health professional check your feet for any sores or irritations? (CHECK ALL THAT APPLY)
	During 2011
	During 2010
	During 2009
	Before 2009
	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 2011
	During 2010
	During 2009
	Before 2009
	Never

5.	Which of the following year(s) did you have your blood cholesterol checked? (CHECK ALL THAT APPLY)
	During 2011
	During 2010
	During 2009
	Before 2009
	Never

6.	Which of the following year(s) did you get a flu vaccination (shot or nasal spray)? (CHECK ALL THAT APPLY)
	During 2011
	During 2010
	During 2009
	Before 2009
	Never

7.	Has your diabetes caused problems with your kidneys?
	Yes
	No

8.	Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist?
	Yes
	No

9.	Is your diabetes being treated by modifying your diet?
	Yes
	No

10.	Is your diabetes being treated by medications taken by mouth?
	Yes
	No

11.	Is your diabetes being treated with insulin injections?
	Yes
	No

12.	During the last 12 months, have you learned how to take care of your diabetes?
	Yes
	No (skip Q 14)

13.	Which of the following methods have you used to learn to take care of your diabetes? [CHECK ALL THAT APPLY]
	Talking to a doctor/health professional within your primary care practice
	Talking to a doctor/health professional not in your primary care practice
	Telephone call with a health professional
	Reading about it on the Internet
	Taking a group class
	Other (specify)

14.	How confident are you in taking care of your diabetes?
	Not confident at all
	Somewhat confident
	Confident
	Very confident
	Refused
	Don’t know

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?

____________________________________________________________________________________

Data Year 2010
11-230

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A Survey About Your Diabetes Care

A Survey About Your Diabetes Care

Thank you for taking the time to complete this important survey.

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Agency for Healthcare Research and Quality

Thank you for taking the time to complete
this important survey.