Self 2004
Medical Expenditure Panel Survey
A Survey About Your Diabetes Care
The care of people with diabetes is an important concern ofthe Public
Health Service. Please take a few minutes to answer the following questions
on the care you received for your diabetes.Your participation is voluntary
and all ofyour answers will be kept confidential. Ifyou have any questions
about this survey, please call Alex Scott at 1-800-945-MEPS (6377).
This survey should be completed by
NAME:
DOB:
PID:
RUID:
When you have completedthe survey, please fold it, seal it with this
label, and place it in the envelope provided.
The Agency for Healthcare Research and Quality and The National Center
for Health Statistics of the U.S.Public Health Service
OMB # 0935-0104
A Survey About Your Diabetes Care
Instructions: Answer every question by checking one box or filling in
a number as indicated.
If you are unsure about how to answer a question, please give the best
answer you can.
1. Have you ever been told by a doctor or other health professional that
you have diabetes or
sugar diabetes? (CHECK ONE)
Yes......................................Please continue.
No......................................Thank you for your time. This
survey is complete.
2. During 2003, how many times did a doctor, nurse, or other health
professional check you for
glycosylated hemoglobin or “hemoglobin A-one-C”? (FILL IN
NUMBER OF TIMES)
Number of Times ......................
Never........................................
Don't know................................
3. During 2003, how many times did a health professional check your
feet for any sores or irritations?
(FILL IN NUMBER OF TIMES)
Number of Times ......................
Never........................................
4. Which of the following year(s) did you have an eye exam in which
your pupils were dilated?
This would have made you temporarily sensitive to bright light.(CHECK
ALL THAT APPLY)
During 2004 ..............................
During 2003 ..............................
During 2002 ..............................
Before 2002 ..............................
Never........................................
5. Has your diabetes caused problems with your kidneys?
Yes ............................................
No..............................................
6. Has your diabetes caused problems with your eyes that needed to be
treated by an ophthalmologist?
Yes ............................................
No..............................................
7. Is your diabetes being treated by modifying your diet?
Yes ............................................
No..............................................
8. Is your diabetes being treated by medications taken by mouth?
Yes ............................................
No..............................................
9. Is your diabetes being treated with insulin injections?
Yes ............................................
No..............................................
Thank you for taking the time to complete
this important survey.
Please remember to fold it, seal it, and place it in the envelope provided.
Date completed:
If this survey was not completed by the person named on the front page,
who completed the survey?
What is this person's relationship to the person named on the front page?
What is the reason the person named on the front page did not complete
the survey himself/herself?
This survey is part of the Medical Expenditure Panel Survey, conducted
by the U.S. Public Health Service.
This survey is authorized under Section 902(a) of the Public Health Service
Act [42 U.S.C.299a].The confidentiality
of personal information is protected by Federal Statutes, Section 924(c)
and Section 308(d) of the Public Health Service
Act [42 U.S.C.299c-3(c) and 242m(d)].This law prohibits release of personal
information outside the public health
agencies sponsoring the survey or their contractors without first obtaining
permission from the person who gave the
information. The Federal government requires that all persons asked to
respond to one of its surveys be given the
following information: Public reporting burden for this collection of
information is estimated to average 5 minutes per
interview, the estimated time required to complete the “A Survey
About Your Diabetes Care.” Send comments
regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden, to:
Reports Clearance Officer
Attention: PRA,
United States Public Health Service Paperwork Reduction Project (0935-0098)
Hubert H. Humphrey Building,
Room 721-B200
Independence Avenue, SW
Washington, DC 20201
14903.1103.30657
04-230
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