Font Size:

Form Approved
OMB# 0935-0118
Exp. Date 12/31/2015

FOR OFFICE USE

REGION: ____	RUID: ____________
PID: _____	SEX: ___

2014

Medical Expenditure Panel Survey (MEPS)

Your Choices About Your Health

There are a lot of clinical preventive care services available, such as screening tests for different types of cancer or heart disease. Not everyone makes the same choices about which tests to have, when to have a particular test or how often. By answering this questionnaire, you will help MEPS learn about the different choices different people make about preventive care.

This Booklet
Should Be
Completed By

NAME: ___________________________________________

Date of Birth:

MONTH ___

DAY ___

YEAR __________

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 booklet, please call Alex Scott at 1-800-945-MEPS (6377).

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 7 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, 5600 Fishers Lane, Rockville, MD 20857.

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

Please mark an X to answer each question.

1.	Are you male or female?
	Male
	Female Please call Alex Scott, toll free at 1-800-945-6377 before completing.

2.	What is your age?
	_____ Age in years

3.	When was the last time you visited a doctor or nurse for a check-up, follow-up care for an ongoing problem, or a concern that you have about your health? Do not include times you were hospitalized overnight or visits to the hospital emergency room.
	Within the past 12 months
	Within the past one to two years
	Within the past one to five years
	More than five years ago
	Never

4.	During the past 12 months, have you had either a flu shot (directly in the arm or into the skin) or a flu vaccine that was sprayed in your nose?
	Yes
	No

5.	In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
	Yes
	No

6.	About how much do you weigh without shoes?
	_____ Weight (pounds)

7.	About how tall are you without shoes?
	_____ Feet _____ Inches

8.	In the past 12 months, has a doctor, nurse, or other health care professional given you advice about how to manage your weight, discussed weight loss goals with you, or referred you to a weight loss program to help with your diet and exercise?
	Yes
	No

Return To Top

9.	In the last 12 months, has a doctor, nurse, or other health professional asked you how much and how often you drink alcohol? You may have answered in person, on paper, or on a computer.
	Yes
	No

10.	In the last 12 months, have you had 5 or more drinks in one day? (A drink refers to one 12 oz. beer, 5 oz. glass of wine, or 1.5 oz. shot of hard liquor.)
	Yes
	No

11.	In the last 12 months, has a doctor, nurse, or other health care professional advised you to cut back or stop drinking alcohol?
	Yes
	No

12.	Has a doctor, nurse, or other health care professional ever asked you if you smoke or use tobacco? You may have answered in person, on paper, or on a computer.
	Yes
	No

13.	In the last 12 months, on average, would you say you smoked cigarettes or used tobacco every day, some days, or not at all?
	Every day
	Some days
	Not at all Skip to Question 17

14.	In the past 12 months, were you advised by a doctor, nurse, or other health care professional to quit smoking or quit using tobacco?
	Yes
	No

15.	In the past 12 months, were you advised by a doctor, nurse, or other health care professional to take a medication to assist you with quitting smoking or using tobacco? Some medications that can be used are: nicotine gum, patch, nasal spray, inhaler, or prescription medicine.
	Yes
	No

Return To Top

16.	In the past 12 months, has a doctor, nurse, or other health care professional discussed or provided methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or program to help stop smoking.
	Yes
	No

17.	In the past 12 months, has your doctor, nurse, or other health care professional asked you about your mood, such as whether you are anxious or depressed? You may have answered in person, on paper, or on a computer.
	Yes
	No

18.	During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional?
	Yes
	No

19.	Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other health care professional?
	Yes
	No

20.	Within the past 5 years, have you been tested for HIV, the virus that causes AIDS? Include blood testing and/or testing fluid from your mouth.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

Return To Top

If you are 50 or older, please continue to the next questions.

If you are under 50 years old, please go to the back cover section.

21.	Have you ever had a pneumonia shot? A pneumonia shot or pneumococcal vaccine is usually only given once or twice in a person's lifetime.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

22.	Have you had the shingles vaccine? The vaccine is called Zostavax®, the zoster vaccine, or the shingles vaccine. The chicken pox virus causes shingles. The vaccine has been available since May 2006.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

23.	Is there any medical reason why you cannot take aspirin, such as an allergy, another medication you take, or other side effect?
	Yes Skip to Question 25
	No

24.	Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to prevent heart attack or stroke?
	Yes
	No

25.	Have you had colon cancer or your entire colon removed?
	Yes Skip to Question 29
	No

26.	Within the past 10 years, have you had a colonoscopy? A colonoscopy test examines the bowel by inserting a tube into the rectum. After a colonoscopy, you feel tired and usually need someone to drive you home.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

27.	Within the past 5 years, have you had a sigmoidoscopy? A sigmoidoscopy test also examines the bowel by inserting a tube into the rectum. You are awake during this test and can drive yourself home.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

28.	Within the past 12 months, have you had a blood stool test using a home kit? A doctor, nurse, or other health professional provides you a special kit or cards to use at home to determine whether the stool contains blood.
	Yes
	No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
	No, for any other reason

Return To Top

If you are 65 or older, please answer questions 34 and 35.

If you are under 65 years old, please go to the back cover section.

29.	Have you had prostate cancer?
	Yes Please go to the back cover section.
	No

30.	About how old were you the last time you had a PSA test? A "P-S-A" is a blood test to detect prostate cancer. It is also called a prostate specific antigen test.
	Never had a PSA test
	Under age 50
	Between 51 and 64
	Between 65 and 74
	75 or older

Return To Top

Back Cover

Date completed: MONTH __ / DAY __ / YEAR _______

THANK YOU FOR COMPLETING THE QUESTIONNAIRE !

Please place this survey in the envelope provided to you and give it to the
MEPS interviewer.

If the interviewer is no longer available, place the survey in the return envelope
provided to you by the interviewer. If the envelope is missing, mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850

Return To Top

MEPS HOME . CONTACT MEPS . MEPS FAQ . MEPS SITE MAP . MEPS PRIVACY POLICY . ACCESSIBILITY . VIEWERS & PLAYERS . COPYRIGHT

Connect With Us

To sign up for updates or to access your subscriber preferences, please enter your email address below.

5600 Fishers Lane
Rockville, MD 20857
Telephone: (301) 427-1364

Medical Expenditure Panel Survey (MEPS)

Your Choices About Your Health

Please mark an X to answer each question.

Back Cover

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality