Self 2007
Medical Expenditure Panel Survey
MEPS
A Survey About Your Diabetes Care
The care of people with diabetes is an important concern of the 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
of your answers will be kept confidential. If you 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 completed
the 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 Centers for Disease Control and Prevention 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 2006, how many times did
a doctor, nurse, or other health
professional check your blood for
glycosylated hemoglobin or “hemoglobin
A-one-C”? (FILL IN NUMBER OF TIMES)
Number of Times ...................... ____
Did not have a blood test ..........
Don't know ................................
Never ........................................
3. During 2006, 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 2007 ..............................
During 2006 ..............................
During 2005 ..............................
Before 2005 ..............................
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..............................................
10. During the last 6 months, have you
received any of the following to teach
you how to take care of your diabetes:
Telephone call to your house
Yes ............................................
No..............................................
Appointment with nurse
Yes ............................................
No..............................................
Visit to your home
Yes ............................................
No..............................................
Referral to a specialist
Yes ............................................
No..............................................
11. About how long has it been since you
had your blood cholesterol checked by a
doctor or other health professional?
WITHIN PAST YEAR ....................
WITHIN PAST 2 YEARS ................
WITHIN PAST 3 YEARS ................
WITHIN PAST 5 YEARS ................
MORE THAN 5 YEARS ................
NEVER ........................................
12. About how long has it been since you
had a flu shot?
WITHIN PAST YEAR ....................
WITHIN PAST 2 YEARS ................
WITHIN PAST 3 YEARS ................
WITHIN PAST 5 YEARS ................
MORE THAN 5 YEARS ................
NEVER ........................................
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-B
200 Independence Avenue, SW
Washington, DC 20201
21054.1006.76902505
Data Year 2006
07-230
|