Form Approved
OMB# 0935-0118
Exp. Date: 12/31/2018
2017
Your Health and Health Opinions
Your opinion matters!
Medical Expenditure Panel Survey (MEPS)
Understanding how people feel about their health and health care is an important goal of MEPS. Please take a few minutes to answer the questions in this booklet.
Survey Instructions
- Please answer every question by marking one box
"." If you are unsure about how to
answer a question, please give the best answer you can.
- You are sometimes told to skip over some questions in this survey. When this happens you will see arrows that tell you what questions to answer next, like this:
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Yes |
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No If No, go to 3 |
Next Question |
- 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).
- Store your completed booklet in the envelope provided. Have it ready to give to your interviewer at his or her next visit.
This Booklet Should Be Completed By |
Region: |
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RUID: |
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PID: |
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Name: |
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DOB: |
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Month / Day / Year |
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, Room #07W42, Rockville, MD 20857.
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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 |
2. |
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? |
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Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf |
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Yes, limited a lot |
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Yes, limited a little |
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No, not limited at all |
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Climbing several flights of stairs |
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Yes, limited a lot |
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Yes, limited a little |
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No, not limited at all |
3. |
During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities
as a result of your physical health? |
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a. |
Accomplished less than you would like as a result of your physical health |
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No, none of the time |
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Yes, a little of the time |
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Yes, some of the time |
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Yes, most of the time |
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Yes, all of the time |
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Were limited in the kind of work or other activities as a result of your physical health |
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No, none of the time |
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Yes, a little of the time |
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Yes, some of the time |
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Yes, most of the time |
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Yes, all of the time |
4. |
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)? |
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Accomplished less than you would like as a result of any emotional problems |
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No, none of the time |
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Yes, a little of the time |
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Yes, some of the time |
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Yes, most of the time |
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Yes, all of the time |
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Didn’t do work or other activities as carefully as usual as a result of any emotional problems |
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No, none of the time |
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Yes, a little of the time |
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Yes, some of the time |
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Yes, most of the time |
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Yes, all of the time |
These questions are about how you feel and how things have been with you during the during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
8. |
The following questions ask about how you have been feeling during the past 30 days. For each question, please mark the box that best describes how often you had this feeling. |
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During the past 30 days, about how often did you feel... |
All of the time |
Most of the time |
Some of the time |
A little of the time |
None of the time |
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...nervous? |
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b. |
...hopeless? |
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...restless or fidgety? |
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...so sad that nothing could cheer you up? |
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...that everything was an effort? |
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...worthless? |
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9. |
The following two questions ask about how you have been feeling in the past 2 weeks. |
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Over the last 2 weeks, how often have you been bothered by any of the following problems? |
Nearly every day |
More than half the days |
Several days |
Not at all |
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Little interest or pleasure in doing things. |
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b. |
Feeling down, depressed, or hopeless. |
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Return to Start
10. |
For the four statements below, please mark one of the boxes to indicate how strongly you agree or disagree for each statement. If you are uncertain, mark the box for uncertain. |
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Disagree strongly |
Disagree somewhat |
Uncertain |
Agree somewhat |
Agree strongly |
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a. |
I’m healthy enough that I really don’t need health insurance. |
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b. |
Health insurance is not worth the money it costs. |
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I’m more likely to take risks than the average person. |
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I can overcome illness without help from a medically trained person. |
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Return to Start
These questions ask about your own health care. Do not include care you got when you stayed
overnight in a hospital. Do not include the times you went for dental care visits.
Return to Start
When you answer the next questions, do not include dental visits or care you got when you stayed
overnight in a hospital.
Date completed:
Who completed this form? |
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Person named on front of this form |
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Someone else,
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If Someone Else, what is person’s relationship to the person named on the front of this form? |
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Husband or wife |
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Unmarried partner |
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Mother, father, or guardian |
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Son or daughter |
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Other relative |
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Not related |
Thank you for taking the time to complete this survey.
Remember to store it in the envelope provided.
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