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Form Approved
OMB# 0935-0118
Exp. Date 12/31/2018

Your Health and Health Opinions

Your opinion matters!

Medical Expenditure Panel Survey (MEPS)

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

REGION: RUID: PID:

NAME:

DOB: SEX:

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, 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

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Your Choices about Your Health
If You are 50 or Older

Your Health And Health Choices

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Are you male or female?

Male Please call Alex Scott, toll free at 1-800-945-6377 before completing

Female

What is your age?

Under 18

18 to 34

35 to 49

50 or older

In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor

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?

Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

Yes, limited a lot

Yes, limited a little

No, not limited at all

Climbing several flights of stairs

Yes, limited a lot

Yes, limited a little

No, not limited at all

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?

Accomplished less than you would like as a result of your physical health

No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time

Were limited in the kind of work or other activities as a result of your physical health

No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time

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)?

Accomplished less than you would like as a result of any emotional problems

No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time

Didn't do work or other activities as carefully as usual as a result of any emotional problems

No, none of the time

Yes, a little of the time

Yes, some of the time

Yes, most of the time

Yes, all of the time

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

Not at all

A little bit

Moderately

Quite a bit

Extremely

These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks:

Have you felt calm and peaceful?

All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time

Did you have a lot of energy?

All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time

Have you felt downhearted and blue?

All of the time

Most of the time

A good bit of the time

Some of the time

A little of the time

None of the time

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

10.

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.

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

nervous?

hopeless?

restless or fidgety?

so sad that nothing could cheer you up?

that everything was an effort?

worthless?

11.

The following two questions ask about how you have been feeling in the past 2 weeks.

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

Little interest or pleasure in doing things...

Feeling down, depressed, or hopeless....

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Your Choices about Your Health

12.

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 two to five years

More than five years ago

Never

12.

In the past 12 months, have you received counseling or information about birth control from a doctor or other medical care provider?

Yes

13.

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

14.

In the past 12 months, has a doctor, nurse, or other health care professional weighed you?

Yes

15.

About how much do you weigh without shoes?

Weight (pounds)

16.

About how tall are you without shoes?

Feet

Inches

17.

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

18.

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

19.

In the last 12 months, have you had 4 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

20.

In the last 12 months, has a doctor, nurse, or other health care professional advised you to cut back or stop drinking alcohol?

Yes

21.

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

22.

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 26

23.

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

24.

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

25.

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

26.

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

27.

During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional?

Yes

28.

Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other health care professional?

Yes

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If you are 50 or older, please continue with the questions.
If you are under 50 years old, please go to the “Date Completed” box on the last page.

29.

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

30.

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

31.

Is there any medical reason why you cannot take aspirin, such as an allergy, another medication you take, or other side effect?

Yes If Yes, go to 33

32.

Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to prevent heart attack or stroke?

Yes

33.

Have you had colon cancer or your entire colon removed?

Yes If Yes, go to 37

34.

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

35.

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

36.

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

37.

Have you had prostate cancer?

Yes If Yes, go to the “Date Completed” box on the back cover

38.

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

Who completed this form?

Person named on front of this form

Someone else,

If Someone Else, what is person’s relationship to the person named on the front of this form?

Husband or wife

Unmarried partner

Mother, father, or guardian

Son or daughter

Other relative

Not related

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

Data Year 2015
15-233.F

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Your Health and Health Opinions

Your opinion matters!

Medical Expenditure Panel Survey (MEPS)

Your Health And Health Choices

Start Here

Your Choices about Your Health

If you are 50 or older, please continue with the questions. If you are under 50 years old, please go to the “Date Completed” box on the last page.

THANK YOU FOR COMPLETING THE QUESTIONNAIRE!

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Agency for Healthcare Research and Quality

If you are 50 or older, please continue with the questions.
If you are under 50 years old, please go to the “Date Completed” box on the last page.