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Form Approved
OMB# 0935-0118
Exp. Date: 12/31/2018

2016

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 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 be told what questions to answer next, otherwise, go to the next question.

This Booklet Should
Be Completed By

Region:

RUID:

PID:

Name:

Version:

DOB:

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).

Store your completed booklet in the envelope provided. Have it ready to give to your interviewer at his or her next visit.

This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. 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. 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 (0935-0118)AHRQ, 5600 Fishers Lane, Room #07W42, Rockville, MD 20857.

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

Your Health Care in the Last 12 Months

In the last 12 months, did you have an illness, injury, or condition that needed care right away in a clinic, emergency room, or doctor's office?

Yes

No Skip to Question 3

In the last 12 months, when you needed care right away, how often did you get care as soon as you thought you needed?

Never

Sometimes

Usually

Always

In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

Yes

No Skip to Question 5

In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?

Never

Sometimes

Usually

Always

In the last 12 months, not counting the times you went to an emergency room, how many times did you go to a doctor’s office or clinic to get health care for yourself?

None Skip to Question 18

5 to 9

10 or more

In the last 12 months, did you or a doctor believe you needed any care, tests, or treatment?

Yes

No Skip to Question 8

In the last 12 months, how often was it easy to get the care, tests, or treatment you or a doctor believed necessary?

Never

Sometimes

Usually

Always

In the last 12 months, how often did doctors or other health providers listen carefully to you?

Never

Sometimes

Usually

Always

In the last 12 months, how often did doctors or other health providers explain things in a way that was easy to understand?

Never

Sometimes

Usually

Always

10.

In the last 12 months, how often did doctors or other health providers show respect for what you had to say?

Never

Sometimes

Usually

Always

11.

In the last 12 months, how often did doctors or other health providers spend enough time with you?

Never

Sometimes

Usually

Always

12.

In the last 12 months, did a doctor or other health provider give you instructions about what to do about a specific illness or health condition?

Yes

No Skip to Question 15

13.

In the last 12 months, how often were these instructions easy to understand?

Never

Sometimes

Usually

Always

14.

In the last 12 months, how often did doctors or other health providers ask you to describe how you were going to follow these instructions?

Never

Sometimes

Usually

Always

15.

In the last 12 months, did you have to fill out or sign any forms at a doctor’s or other health provider’s office?

Yes

No Skip to Question 17

16.

In the last 12 months, how often were you offered help in filling out a form at the doctor’s or other health provider’s office?

Never

Sometimes

Usually

Always

17.

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?

0 Worst health care possible

10 Best health care possible

18.

Do you currently smoke?

Yes

No Skip to Question 20

19.

In the last 12 months, did a doctor advise you to quit smoking?

Yes

Had no visits in the last 12 months

20.

In the last 2 years, has your blood pressure been checked by a doctor, nurse, or other health professional?

Yes

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Getting Health Care from a Specialist

When you answer the next questions, do not include dental visits.

21.

Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care.

In the last 12 months, did you or a doctor think you needed to see a specialist?

Yes

No Skip to Question 23

22.

In the last 12 months, how often was it easy to see a specialist that you needed to see?

Never

Sometimes

Usually

Always

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General Health

23.

In general, would you say your health is:

Excellent

Very good

Good

Fair

Poor

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?

24.

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

25.

Climbing several flights of stairs

Yes, limited a lot

Yes, limited a little

No, not limited at all

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?

26.

Accomplished less than you would like

All of the time

Most of the time

Some of the time

A little of the time

None of the time

27.

Were limited in the kind of work or other activities

All of the time

Most 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 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)?

28.

Accomplished less than you would like

All of the time

Most of the time

Some of the time

A little of the time

None of the time

29.

Did work or other activities less carefully than usual

All of the time

Most of the time

Some of the time

A little of the time

None of the time

30.

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:

31.

Have you felt calm and peaceful?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

32.

Did you have a lot of energy?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

33.

Have you felt downhearted and depressed?

All of the time

Most of the time

Some of the time

A little of the time

None of the time

34.

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting 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 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

35.

...nervous?

36.

...hopeless?

37.

...restless or fidgety?

38.

...so sad that nothing could cheer you up?

39.

...that everything was an effort?

40.

...worthless?

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

41.

Little interest or pleasure in doing things.

42.

Feeling down, depressed, or hopeless.

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Opinions about Health

For items 43-46, please mark one of the boxes to indicate how strongly you agree or disagree for each statement. If you are uncertain,mark the box for uncertain (3).

Disagree strongly

Disagree somewhat

Uncertain

Agree somewhat

Agree strongly

43.

I’m healthy enough that I really don’t need health insurance.

44.

Health insurance is not worth the money it costs.

45.

I’m more likely to take risks than the average person.

46.

I can overcome illness without help from a medically trained person.

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Date completed: MONTH ____ / DAY ____ / YEAR __________

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:

__________________________

Thank you for taking the time to complete this survey.

Remember to seal it and place it in the envelope provided.

SF12v2™ Health Survey ^© 1994, 2002 by QualityMetric Incorporated and Medical Outcomes Trust. All Rights Reserved.
SF12^® a registered trademark of Medical Outcomes Trust.
(SF12v2 Standard, US Version 2.0)

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