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Form Approved
OMB# 0935-0118
Exp. Date: 11/30/2021

2019

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 see arrows that tell you what questions to answer next, like this:

Yes

No If No, go to 3

Next Question

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 Booklet Should Be Completed By

Region:

RUID:

PID:

Name:

DOB:

Month / Day / Year

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

General Health

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 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 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

...nervous?

...hopeless?

...restless or fidgety?

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

...that everything was an effort?

...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

Little interest or pleasure in doing things.

Feeling down, depressed, or hopeless.

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Opinions about Health

10.

For the four statements below, 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.

Disagree strongly

Disagree somewhat

Uncertain

Agree somewhat

Agree strongly

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

Health insurance is not worth the money it costs.

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

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

Return to Start

Your Health Care in the Last 12 Months

These questions ask about your own health care. Do not include care you got when you stayed overnight in a hospital. Do not include the times you went for dental care visits.

11.

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 If No, go to 13

12.

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

13.

In the last 12 months, did you make any appointments for a check-up or routine care at a doctor’s office or clinic?

Yes

No If No, go to 15

14.

In the last 12 months, how often did you get an appointment for a check-up or routine care at a doctor’s office or clinic as soon as you needed?

Never

Sometimes

Usually

Always

15.

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 If No, go to 26

1 time

5–9

10 or more times

16.

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

17.

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 If No, go to 20

18.

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

Never

Sometimes

Usually

Always

19.

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

20.

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 If No, go to 22

21.

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

22.

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

Never

Sometimes

Usually

Always

23.

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

Never

Sometimes

Usually

Always

24.

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

Never

Sometimes

Usually

Always

25.

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

Never

Sometimes

Usually

Always

26.

Do you currently smoke?

Yes

No If No, go to 28

27.

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

Yes

Had no visits in the last 12 months

Return to Start

Getting Health Care from a Specialist

When you answer the next questions, do not include dental visits or care you got when you stayed overnight in a hospital.

28.

Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other doctors who specialize in one area of health care. In the last 12 months, did you make any appointments to see a specialist?

Yes

No If No, please go to the “Date completed” boxes below

29.

In the last 12 months, how often did you get an appointment to see a specialist as soon as you needed?

Never

Sometimes

Usually

Always

Date completed:

Who completed this form?

Person named on front of this form

Someone else,