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.
![Department of Health and Human Services (HHS) 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 |
1. |
Are you male or female? |
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![empty check box](images/empty_checkbox.gif) |
Male Please call Alex Scott, toll free at 1-800-945-6377 before completing |
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Female |
4. |
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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a. |
Moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf |
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1![empty check box](images/empty_checkbox.gif) |
Yes, limited a lot |
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2![empty check box](images/empty_checkbox.gif) |
Yes, limited a little |
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3![empty check box](images/empty_checkbox.gif) |
No, not limited at all |
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b. |
Climbing several flights of stairs |
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1![empty check box](images/empty_checkbox.gif) |
Yes, limited a lot |
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2![empty check box](images/empty_checkbox.gif) |
Yes, limited a little |
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3![empty check box](images/empty_checkbox.gif) |
No, not limited at all |
5. |
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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b. |
Were limited in the kind of work or other activities as a result of your physical health |
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![empty check box](images/empty_checkbox.gif) |
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 |
6. |
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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a. |
Accomplished less than you would like as a result of any emotional problems |
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![empty check box](images/empty_checkbox.gif) |
No, none of the time |
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![empty check box](images/empty_checkbox.gif) |
Yes, a little of the time |
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![empty check box](images/empty_checkbox.gif) |
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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b. |
Didn't do work or other activities as carefully as usual as a result of any emotional problems |
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![empty check box](images/empty_checkbox.gif) |
No, none of the time |
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![empty check box](images/empty_checkbox.gif) |
Yes, a little of the time |
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![empty check box](images/empty_checkbox.gif) |
Yes, some of the time |
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![empty check box](images/empty_checkbox.gif) |
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 past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
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. |
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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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a. |
nervous? |
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b. |
hopeless? |
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c. |
restless or fidgety? |
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d. |
so sad that nothing could cheer you up? |
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e. |
that everything was an effort? |
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f. |
worthless? |
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11. |
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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a. |
Little interest or pleasure in doing things... |
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b. |
Feeling down, depressed, or hopeless.... |
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12. |
In the past 12 months, have you received counseling or information about birth control from a doctor or other medical care provider? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
14. |
In the past 12 months, has a doctor, nurse, or other health care professional weighed you? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
15. |
About how much do you weigh without shoes? |
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Weight (pounds) |
16. |
About how tall are you without shoes? |
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Feet |
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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? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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. |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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.) |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
20. |
In the last 12 months, has a doctor, nurse, or other health care professional advised you to cut back or stop drinking alcohol? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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. |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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. |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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. |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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. |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
27. |
During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
28. |
Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other health care professional? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
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32. |
Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to prevent heart attack or stroke? |
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![empty check box](images/empty_checkbox.gif) |
Yes |
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![empty check box](images/empty_checkbox.gif) |
No |
If Someone Else, what is person’s relationship to the person named on the front of this form? |
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![empty check box](images/empty_checkbox.gif) |
Husband or wife |
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![empty check box](images/empty_checkbox.gif) |
Unmarried partner |
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![empty check box](images/empty_checkbox.gif) |
Mother, father, or guardian |
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![empty check box](images/empty_checkbox.gif) |
Son or daughter |
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![empty check box](images/empty_checkbox.gif) |
Other relative |
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![empty check box](images/empty_checkbox.gif) |
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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