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Form Approved
OMB# 0935-0118
Exp. Date 9/30/2026

2025

Understanding Your Health and Impacts of Healthcare Costs

Your opinion matters!

Medical Expenditure Panel Survey (MEPS)

This survey asks about your general well-being and how health needs impact your time or your work. Your participation will help us better understand how health and health care affect people’s lives.

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:

Yes

No If No, go to question 3

Next Question
Your participation is voluntary and all of your answers will be kept confidential as required by law. If you have any questions about this booklet, please call Alex Scott at 1-800-945-MEPS (6377).
If you choose to complete the survey, MEPS will mail you a $20 debit card.

This Booklet Should Be Completed By

RUID: PID:

NAME:

DOB:

This survey is authorized under 42 U.S.C. 299a. Privacy is protected by the Privacy Act and Section 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. The confidentiality of your responses to this survey is protected by Section 944(c) of the Public Health Service Act. 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 10 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. This information collection is voluntary. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more accessible, equitable, and affordable. 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 (OMB control number 0935-0118) AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857 or by email at REPORTSCLEARANCEOFFICER@ahrq.hhs.gov.

Department of Health and Human Services (DHHS)

The Agency for Healthcare Research and Quality of
the U.S. Department of Health and Human Services

EQ-5D-5L Health Questionnaire
Time and Paying for Health Care
Impacts on Work
Informal Caregiving

EQ-5D-5L Health Questionnaire

Under each heading, please check the ONE box that best describes your health TODAY.

MOBILITY

I have no problems walking

I have slight problems walking

I have moderate problems walking

I have severe problems walking

I am unable to walk

SELF-CARE

I have no problems washing or dressing myself

I have slight problems washing or dressing myself

I have moderate problems washing or dressing myself

I have severe problems washing or dressing myself

I am unable to wash or dress myself

USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)

I have no problems doing my usual activities

I have slight problems doing my usual activities

I have moderate problems doing my usual activities

I have severe problems doing my usual activities

I am unable to do my usual activities

PAIN / DISCOMFORT

I have no pain or discomfort

I have slight pain or discomfort

I have moderate pain or discomfort

I have severe pain or discomfort

I have extreme pain or discomfort

ANXIETY / DEPRESSION

I am not anxious or depressed

I am slightly anxious or depressed

I am moderately anxious or depressed

I am severely anxious or depressed

I am extremely anxious or depressed

The best health you can imagine

We would like to know how good or bad your health is TODAY.
This scale is numbered from 0 to 100.
100 means the best health you can imagine.
0 means the worst health you can imagine.
Mark an X on the scale to indicate how your health is TODAY.
Now, please write the number you marked on the scale in the box below.

YOUR HEALTH TODAY =

Scale from 0 to 100 shown in increments of one.

The worst heath you can imagine

© EuroQol Research Foundation. EQ-5D™ is a trade mark of the EuroQol Research Foundation. USA (English) v1.2

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Time and Paying for Health Care

For each item on this page, please report the total hours by week, by month, or for the last year.

Please think of how much time you spend seeing doctors, nurses, therapists or other health care providers about your own health, or going to the pharmacy for your own medications.

During the past year, about how much time did you spend on average on these activities, including travel time?

hours per week

hours per month

hours last year

Please think of how much time you spend taking other people to see doctors, nurses, therapists or other health care providers, or going to the pharmacy for their medications.

During the past year, about how much time did you spend on average on these activities, including travel time?

hours per week

hours per month

hours last year

During the past year, about how much time did you spend on average paying or managing medical bills, including dealing with insurance claims? If you helped another person manage his or her bills or claims, please include that time.

hours per week

hours per month

hours last year

10.

During the past year, about how much time did you spend on average filling out forms, finding a doctor or other health provider who will see you, finding or understanding health plan information, and getting approval for any care, tests, or treatment? If you helped another person with these tasks, please include that time.

hours per week

hours per month

hours last year

11.

In the past year, did your health insurance deny or delay prior approval for a treatment, service, visit, or drug before you received it?

Yes

Never had health insurance during past year

Not applicable/haven’t used services

12.

Suppose you had an unexpected medical bill, and the amount not covered by any insurance you may have came to $500, how would you pay the bill?

Pay the bill right away by cash, check, or debit card

Pay the bill right away out of your Health Savings Account or Flexible Savings Account

Put it on a credit card and pay it off in full at the next statement

Put it on a credit card and pay it off over time

Borrow money from a bank, a payday lender, or friends or family to pay the bill

Make a payment plan with provider

Would not be able to pay the bill at all

Something else

13.

In the past year, have you or your family had to make any financial sacrifices because of your physical or mental health or its treatment?
Mark

all that apply.

Reduced spending on vacation or leisure activities

Delayed large purchases (e.g., car)

Reduced spending on basics (e.g., food and clothing)

Used savings set aside for other purposes (e.g., retirement, educational funds, family support)

Made a change to living situation (e.g., sold, refinanced, or moved to a smaller residence)

Other

No sacrifices

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Impacts On Work

14.

At any time in the past year, were you working for pay at a job or business (including being self-employed)?

Yes

No If No, go to question 22

15.

Because of your physical or mental health or its treatment, did any of your employers do anything to help you out so that you can continue working in the past year?
Mark

all that apply.

I didn’t need any help from my employers

Get someone to help me with my work duties

Shorten my work days

Allow me to change the time I came to and left work

Allow me more breaks and rest periods

Change the job to something I could do

Help me learn new skills or get me special equipment or a computer for the job

Assist me in receiving rehabilitative services from an external provider

Allow me to work from home

Something else to help me out

My employers didn’t offer me any help

I’m self-employed

16.

Because of your physical or mental health or its treatment, did you ask any of your employers for help to do your job that you did not receive in the past year?

Yes

No, because I didn’t need any help from my employer

No, because I received all the help I needed

No, but I would have liked to get help (or more help) from my employer

I’m self-employed

17.

In the past year, did you stay at a job in part because you were concerned about losing health insurance for yourself or for the family?

Yes

18.

Because of your physical or mental health or its treatment, have there been days in the past year when you needed to take off from work but did not?

Yes

No If No, go to question 20

19.

Why did you decide not to take time off?
Mark

all that apply.

Too much work

Wanted to save leave

Leave was denied

Did not have any paid or unpaid leave

Did not have enough leave

Fear of job loss or other negative employment-related consequence

Could not afford the loss in income

Other

20.

Now thinking about the past 7 days, were you working for pay at a job or business (including being self-employed)?

Yes

No If No, go to question 22

21.

In the past 7 days, think about days you were limited in the amount or kind of work you could do, days you accomplished less than you would like, or days you could not do your work as carefully as usual.

During the past 7 days, how much did your health problems or mental health affect your productivity while you were working?

If health problems or mental health affected your work only a little, mark a low number. Mark a high number if health problems or mental health affected your work a great deal.

Health problems had no effect on my work

Health problems completely prevented me from working

MARK

A NUMBER

22.

In the past 7 days, think about times you were limited in the amount or kind of regular daily activities you could do (e.g., work around the house, shopping, childcare, exercising, or studying, etc.) and times you accomplished less than you would like.

During the past 7 days, how much did your health problems or mental health affect your ability to do your regular daily activities, other than work at a job?

If health problems or mental health affected your activities only a little, mark a low number. Mark a high number if health problems or mental health affected your activities a great deal.

Health problems had no effect on my daily activities

Health problems completely prevented me from doing my daily activities

MARK

A NUMBER

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Informal Caregiving

23.

During the past 30 days, did you provide regular care or assistance to a friend or family member who has a health problem or disability?

Yes

No If No, go to Date Completed on back cover

24.

What is his or her relationship to you? (If more than one person, please refer to the person to whom you are giving the most care.)

Mother

Father

Child

Husband

Wife

Live-in partner

Other relative

Non-relative/Family friend

25.

Do you live with this person?

Yes

26.

For how long have you provided care for that person?

Less than 30 days

1 month to less than 6 months

6 months to less than 1 year

1 year to less than 2 years

2 years to less than 5 years

5 years or more

27.

In the past 30 days, did you provide care for this person by managing personal care such as giving medications, feeding, dressing, or bathing?

Yes

28.

In the past 30 days, did you provide care for this person by managing household tasks such as cleaning, managing money, or preparing meals?

Yes

29.

In the past 30 days, did you stay with this person to provide help when needed because they cannot be left alone?

Yes

30.

In the past 30 days, did helping this person ever keep you from working for pay (including being self-employed)?

Yes

31.

In an average week, how many hours do you provide care or assistance?

Up to 8 hours per week

9 to 19 hours per week

20 to 39 hours per week

40 hours or more

Questions 23, 24, 26, 27, 28, 31. Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Questionnaire. Atlanta, Georgia: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, [2022]

Question 30. Freedman, Vicki A., Skehan, Maureen E., Hu, Mengyao, Wolff, Jennifer, Kasper, Judith D. 2019. National Study of Caregiving I-III User Guide. Baltimore: Johns Hopkins Bloomberg School of Public Health. Available at www.nhats.org

Date completed:

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 TAKING THE TIME TO COMPLETE THE QUESTIONNAIRE!

Please give your completed survey to your MEPS interviewer or place it in the return envelope and mail it back.
If the envelope is missing, mail this survey to:
- MEPS
  c/o Westat
  1600 Research Blvd, RC B16
  Rockville, MD 20850
MEPS will mail you a $20 debit card after we receive your completed survey.

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