2009
Your Health and Health Opinions
Your Opinion Matters!
Medical Expenditure Panel Survey (MEPS)
Understanding how people feel about their health and health care is an important goal of MEPS. Please take a few minutes to answer the questions in this booklet.
Survey Instructions
- Please answer every question by checking 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:
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This Booklet Should
Be Completed By |
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Name: |
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DOB: |
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Your participation is voluntary and all of your answers will be kept confidential. If you have any questions about this booklet, please call Alex Scott at 1-800-945-MEPS (6377).
When you have completed the booklet, please seal it with this label and place it in the envelope provided. Have it ready to give to your interviewer at his or her next visit.
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. OMB # 0935-0118
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Your Health Care in the Last 12 Months
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Using any number from 0 to 10 where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months? |
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0 Worst health care possible |
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10 Best health care possible |
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In the last 2 years, has your blood pressure been checked by a doctor, nurse, or other health professional? |
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Yes |
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Getting Health Care from a Specialist
When you answer the next questions, do not include dental visits.
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General Health
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
During the past 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
During the past 4 weeks, how much of the time 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)?
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:
The following questions ask about how you have been feeling during the past 30 days. For each question, please place a check mark in the box that best describes how often you had this feeling.
The following two questions ask about how you have been feeling in the past 2 weeks.
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Opinions about Health
For items 38-41, please check one of the boxes to indicate how strongly you agree or disagree for each statement. If you are uncertain, check the box for uncertain (3).
Date completed: _________________________________
If this booklet was not completed by the person named on the front, who completed it:
____________________________________________________________________________________
What is this person’s relationship to the person named on the front:
____________________________________________________________________________________
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SF-12v2™ Health Survey© 1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF-12® a registered trademark of Medical Outcomes Trust. (SF-12v2 Standard, US Version 2.0)
Thank you for taking the time to complete
this survey.
Remember to seal it and place it in the envelope provided.
This survey is part of the Medical Expenditure Panel Survey, conducted by the U.S. Department Health and Human Services. 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 survey about Your Health and Health Opinions. 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
Attn: 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
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