Font Size:

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

2024

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 as well as how people feel about their general health and health care.

Survey Instructions

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).

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 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).

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 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. 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

Start
Alcohol Use
Counseling and Treatment
Your Choices about Your Health
If you are female
If You are 40 or Older
If You are 40 or Older and Female/Male
About You

Your Health And Health Choices

Start Here:

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

The next questions are about how you feel about different aspects of your life. For each one, mark how often you feel that way.

First, how often do you feel that you lack companionship?

Never

Rarely

Sometimes

Often

How often do you feel left out?

Never

Rarely

Sometimes

Often

How often do you feel isolated from others?

Never

Rarely

Sometimes

Often

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?

10.

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...

11.

During the past 30 days, how often have you experienced trouble getting to sleep or staying asleep?

Not at all

Once a month

Several times a month

Once a week

Several times a week

Almost every day

12.

In the past 30 days, other than the activities you did for work, on average, how many days per week did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking, or other similar activities)?

13.

On average, how many minutes did you usually spend exercising at this level on one of those days?

60 or greater

Return to Top

Alcohol Use

14.

Think about your drinking in the past 12 months. A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

How often do you have a drink containing alcohol?

Never If Never, go to question 18

Less than monthly

Monthly

Weekly

2-3 times a week

4-6 times a week

Daily

15.

How many drinks containing alcohol do you have on a typical day you are drinking?
A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

1 drink

2 drinks

3 drinks

4 drinks

5-6 drinks

7-9 drinks

10 or more drinks

16.

How often do you have 4 or more drinks on one occasion?
A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

Never

Less than monthly

Monthly

Weekly

2-3 times a week

4-6 times a week

Daily

17.

How often do you have 5 or more drinks on one occasion?
A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.

Never

Less than monthly

Monthly

Weekly

2-3 times a week

4-6 times a week

Daily

18.

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

Yes

Return to Top

Counseling and Treatment

20.

People can get counseling, treatment or medicine for many different reasons, such as:

For feeling depressed, anxious, or “stressed out”
Personal problems (like when a loved one dies or when there are problems at work)
Family problems (like marriage problems or when parents and children have trouble getting along)
Needing help with drug or alcohol use
For mental or emotional illness

In the last 12 months, did you get counseling, treatment or medicine for any of these reasons?

Yes

21.

During the past 12 months, was there any time when you felt you needed counseling or treatment for yourself but didn't get it?

Yes

22.

In the last 12 months, how much of a problem, if any, was it to get any counseling or treatment you thought you needed?

A big problem

A small problem

Not a problem

Did not seek counseling in the last 12 months

23.

Have you ever worried about your family’s financial stability because of your mental health, its treatment, or lasting effects of that treatment?

Yes

Return to Top

Your Choices about Your Health

24.

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

25.

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

26.

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

Yes

27.

About how much do you weigh without shoes?

Weight (pounds)

28.

About how tall are you without shoes?

Feet

Inches

29.

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

30.

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

31.

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 If Not at all, go to question 35

32.

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

33.

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

34.

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

35.

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

36.

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

Yes

37.

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

Yes

Return to Top

If you are female, continue with the questions on this page.
If you are male, go to the next page.

If Female:

38.

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

Yes

39.

Have you had a hysterectomy or have you ever had cervical cancer?

Yes If Yes, go to next page

40.

Within the past 5 years, have you had a Pap or human papillomavirus (HPV) test? A Pap or HPV test is a routine test in which the doctor takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.

Yes

41.

About how old were you the last time you had a Pap or HPV test?

Younger than 35

35 to 44 years old

45 to 54 years old

55 to 64 years old

65 to 74 years old

75 or older

I have never had a Pap or HPV test

Return to Top

If you are age 40 or older, continue with the questions on this page.
If you are younger than 40, go to question 56.

If 40 or older:

42.

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

43.

Have you had the shingles vaccine? Two shingles vaccines are available: Zostavax^® and Shingrix^® The chicken pox virus causes shingles. Zostavax^® has been available since 2006 and Shingrix^® since 2017.

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

44.

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 question 46

45.

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

Yes

46.

Have you had colon cancer or your entire colon removed?

Yes If Yes, go to next page

47.

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

48.

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

49.

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 40 or older and female, complete the left side of this page.
If you are 40 or older and male, complete the right side of this page.

If Female & 40 or older

50.

Have you ever been told by a doctor, nurse or other health care professional that you have osteoporosis? Osteoporosis is when the bones become fragile and break easily.

Yes If Yes, go to question 52

51.

There are several tests to measure bone density and detect osteoporosis at an early stage, including a DEXA scan. Have you ever had your bone density measured?

Yes

52.

Have you had both breasts removed or have you ever had breast cancer?

Yes If Yes, go to next page

53.

Within the past 2 years, have you had a mammogram? A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.

Yes

GO TO NEXT PAGE.

If Male & 40 or older

54.

Have you had prostate cancer?

Yes If Yes, go to next page

55.

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

No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it

Under age 50

Between 51 and 64

Between 65 and 74

75 or older

GO TO NEXT PAGE.

Return to Top

About You

56.

What is your age?

Under 18

18 to 39

40 to 49

50 or older

57.

What is your current gender?

Female

Male

Non-Binary

I use a different term (specify)

58.

What sex were you assigned at birth, for example on your original birth certificate?

Female

Male

59.

Which of the following best represents how you think of yourself?

Gay or lesbian

Straight, that is, not gay or lesbian

Bisexual

I use a different term (specify)

I don’t know

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

24-233R

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

Your Health and Health Opinions

Your opinion matters!

Your Health And Health Choices

Start Here:

Alcohol Use

Counseling and Treatment

Your Choices about Your Health

If you are female, continue with the questions on this page. If you are male, go to the next page.

If you are age 40 or older, continue with the questions on this page. If you are younger than 40, go to question 56.

If you are 40 or older and female, complete the left side of this page.If you are 40 or older and male, complete the right side of this page.

About You

Date completed:

THANK YOU FOR TAKING THE TIME TO COMPLETE THE QUESTIONNAIRE!

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

If you are female, continue with the questions on this page.
If you are male, go to the next page.

If you are age 40 or older, continue with the questions on this page.
If you are younger than 40, go to question 56.

If you are 40 or older and female, complete the left side of this page.
If you are 40 or older and male, complete the right side of this page.