Form Approved
OMB #0935-0118
Exp. Date 01/31/2016
Self 2013
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 the 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.
![Department of Health and Human Services (DHHS) logo](images/DHHS_logo.jpg) |
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 |
A Survey About Your Diabetes Care
Instructions: Answer each question by checking one box or filling in a number when
necessary. 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 2012, how many times did a doctor,
nurse, or other health professional check
your 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 is 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 needs supplies of disposable test strips.) |
|
If you had this blood test, fill in
NUMBER OF TIMES |
_____ |
|
Did not have A1C blood test |
![empty check box](images/empty_checkbox.gif) |
|
Don't know |
![empty check box](images/empty_checkbox.gif) |
|
Never |
![empty check box](images/empty_checkbox.gif) |
7. |
Has your diabetes caused problems with your kidneys? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
8. |
Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
9. |
Is your diabetes being treated by modifying your diet? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
10. |
Is your diabetes being treated by medications taken by mouth? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
11. |
Is your diabetes being treated with insulin injections? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No |
![empty check box](images/empty_checkbox.gif) |
12. |
During the last 12 months, have you learned how to take care of your diabetes? |
|
Yes |
![empty check box](images/empty_checkbox.gif) |
|
No (Skip to Q 14) |
![empty check box](images/empty_checkbox.gif) |
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 2012
12-230
|