Form Approved
OMB# 0935-0118
Exp. Date 12/31/2022

2020

Your Health and Health Opinions

Your opinion matters!

Medical Expenditure Panel Survey (MEPS)

There are a lot of clinical preventive care services available, such as screening tests for different types of cancer or heart disease. Not everyone makes the same choices about which tests to have, when to have a particular test or how often. By answering this questionnaire, you will help MEPS learn about the different choices different people make about preventive care.

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, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

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

• Start
• Alcohol and Drug Use
• Counseling and Treatment
• Counseling Needs and Alternative Treatments
• Your Choices about Your Health
• If You are 50 or Older

Your Health And Health Choices

Start Here

1.	Are you male or female?
		Male  Please call Alex Scott, toll free at 1-800-945-6377 before completing.
		Female

2.	What is your age?
		Under 18
		18 to 34
		35 to 49
		50 or older

3.	In general, would you say your health is:
		Excellent
		Very good
		Good
		Fair
		Poor

4.	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?
	a.	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
	b.	Climbing several flights of stairs
			Yes, limited a lot
			Yes, limited a little
			No, not limited at all

5.	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?
	a.	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
	b.	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

6.	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)?
	a.	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
	b.	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

7.	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.

8.	How much of the time during the past 4 weeks:
	a.	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
	b.	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
	c.	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

9.	During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
		All of the time
		Most of the time
		Some of the time
		A little of the time
		None of the time

10.	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
	a.	nervous?
	b.	hopeless?
	c.	restless or fidgety?
	d.	so sad that nothing could cheer you up?
	e.	that everything was an effort?
	f.	worthless?

11.	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
	a.	Little interest or pleasure in doing things...
	b.	Feeling down, depressed, or hopeless...

12.	During the past 30 days, how often have you experienced trouble getting to sleep or staying asleep?
		Not at all
		Once a month
		Several times a month
		Once a week
		Several times a week
		Almost every day

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Alcohol and Drug Use

13.	Think about your drinking in the past 12 months. A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.
		Never   If Never, go to 16
		Less than monthly
		Monthly
		Weekly
		2-3 times a week
		4-6 times a week
		Daily

14.	How many drinks containing alcohol do you have on a typical day you are drinking? A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot(1.5 oz.) of spirits.
		1 drink
		2 drinks
		3 drinks
		4 drinks
		5-6 drinks
		7-9 drinks
		10 or more drinks

15.	How often do you have 4 or more drinks on one occasion? A drink means one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot(1.5 oz.) of spirits.
		Never
		Less than monthly
		Monthly
		Weekly
		2-3 times a week
		4-6 times a week
		Daily

16.	In the past 12 months, has a doctor, nurse, or other health care professional asked you how much and how often you drink alcohol? You may have answered in person, on paper, or on a computer.
		Yes
		No

17.	In the past 12 months, has a doctor, nurse, or other health care professional advised you to cut back or stop drinking alcohol?
		Yes
		No

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Counseling and Treatment

20.	People can get counseling, treatment or medicine for many different reasons, such as: For feeling depressed, anxious, or “stressed out” Personal problems (like when a loved one dies or when there are problems at work) Family problems (like marriage problems or when parents and children have trouble getting along) Needing help with drug or alcohol use For mental or emotional illness In the last 12 months, did you get counseling, treatment or medicine for any of these reasons?
		Yes
		No  If No, go to 25

21.	Using any number from 0 to 10, where 0 is the worst counseling or treatment possible and 10 is the best counseling or treatment possible, what number would you use to rate all your counseling or treatment in the last 12 months?
		0   Worst counseling or treatment possible
		1
		2
		3
		4
		5
		6
		7
		8
		9
		10   Best counseling or treatment possible

22.	In the last 12 months, how much were you helped by the counseling or treatment you got?
		Not at all
		A little
		Somewhat
		A lot

23.	How much of the counseling or treatment you got in the last 12 months was paid for by another source besides you or your family?
		All of it
		Most of it
		Some of it
		None of it

24.	In the last 12 months, how much of a problem, if any, was it to get any counseling or treatment you thought you needed?
		A big problem
		A small problem
		Not a problem

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Counseling Needs and Alternative Treatments

25.	During the past 12 months, was there any time when you felt you needed counseling or treatment for yourself but didn’t get it? Think about counseling or treatment for difficult feelings, personal or family problems, drug or alcohol use, or any mental or emotional illness.
		Yes
		No

26.	During the past 12 months, did you ever receive any treatment, counseling, or support including self-help for problems with your emotions, mental health, family or personal problems, or substance use from any of the following other sources?
					Yes	No
	a.	A spiritual or religious advisor...
	b.	A school-based resource...
	c.	An in-person peer support or self-help group...
	d.	An internet website or online support forum or group...
	e.	A telephone hotline...
	f.	A smartphone app...

27.	Have you ever worried about your family’s financial stability because of your mental health, its treatment, or lasting effects of that treatment?
		Yes
		No

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Your Choices about Your Health

28.	In the past 12 months, have you received counseling or information about birth control from a doctor or other medical care provider?
		Yes
		No

29.	When was the last time you visited a doctor or nurse for a check-up, follow-up care for an ongoing problem, or a concern that you have about your health? Do not include times you were hospitalized overnight or visits to the hospital emergency room.
		Within the past 12 months
		Within the past one to two years
		Within the past two to five years
		More than five years ago
		Never

30.	During the past 12 months, have you had either a flu shot (directly in the arm or into the skin) or a flu vaccine that was sprayed in your nose?
		Yes
		No

31.	In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
		Yes
		No

34.	In the past 12 months, has a doctor, nurse, or other health care professional given you advice about how to manage your weight, discussed weight loss goals with you, or referred you to a weight loss program to help with your diet and exercise?
		Yes
		No

35.	Has a doctor, nurse, or other health care professional ever asked you if you smoke or use tobacco? You may have answered in person, on paper, or on a computer.
		Yes
		No

36.	In the last 12 months, on average, would you say you smoked cigarettes or used tobacco every day, some days, or not at all?
		Every day
		Some days
		Not at all  If Not at all, go to 40

37.	In the past 12 months, were you advised by a doctor, nurse, or other health care professional to quit smoking or quit using tobacco?
		Yes
		No

38.	In the past 12 months, were you advised by a doctor, nurse, or other health care professional to take a medication to assist you with quitting smoking or using tobacco? Some medications that can be used are: nicotine gum, patch, nasal spray, inhaler, or prescription medicine.
		Yes
		No

39.	In the past 12 months, has a doctor, nurse, or other health care professional discussed or provided methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or program to help stop smoking.
		Yes
		No

40.	In the past 12 months, has your doctor, nurse, or other health care professional asked you about your mood, such as whether you are anxious or depressed? You may have answered in person, on paper, or on a computer.
		Yes
		No

41.	During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional?
		Yes
		No

42.	Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other health care professional?
		Yes
		No

43.	Have you had a hysterectomy or have you ever had cervical cancer?
		Yes  If yes, go to 46
		No

44.	Within the past 5 years, have you had a Pap test? A Pap smear or Pap test is a routine test in which the doctor takes a cell sample from the cervix with a small stick or brush, and sends it to the lab.
		Yes
		No

45.	About how old were you the last time you had a Pap test?
		Younger than 35
		35 to 44 years old
		45 to 54 years old
		55 to 64 years old
		65 to 74 years old
		75 or older
		I have never had a Pap or HPV test

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If you are 50 or older, please continue with the questions.
If you are under 50 years old, please go to the “Date Completed” box on the last page.

46.	Have you ever had a pneumonia shot? A pneumonia shot or pneumococcal vaccine is usually only given once or twice in a person's lifetime.
		Yes
		No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
		No, for any other reason

47.	Have you had the shingles vaccine? Two shingles vaccines are available: Zostavax® and Shingrix® The chicken pox virus causes shingles. Zostavax® has been available since 2006 and Shingrix® since 2017.
		Yes
		No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
		No, for any other reason

48.	Is there any medical reason why you cannot take aspirin, such as an allergy, another medication you take, or other side effect?
		Yes  If Yes, go to 50
		No

49.	Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to prevent heart attack or stroke?
		Yes
		No

50.	Have you ever been told by a doctor, nurse, or other health care professional that you have osteoporosis? Osteoporosis is when the bones become fragile and break easily.
		Yes  If Yes, go to 52
		No

51.	There are several tests to measure bone density and detect osteoporosis at an early stage, including a DEXA scan. Have you ever had your bone density measured?
		Yes
		No

52.	Have you had both breasts removed or have you ever had breast cancer?
		Yes  If Yes, go to 54
		No

53.	Within the past 2 years, have you had a mammogram? A mammogram is an x-ray taken only of the breast by a machine that presses against the breast.
		Yes
		No

54.	Have you had colon cancer or your entire colon removed?
		Yes  If Yes, go to the “Date Completed” box
		No

55.	Within the past 10 years, have you had a colonoscopy? A colonoscopy test examines the bowel by inserting a tube into the rectum. After a colonoscopy, you feel tired and usually need someone to drive you home.
		Yes
		No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
		No, for any other reason

56.	Within the past 5 years, have you had a sigmoidoscopy? A sigmoidoscopy test also examines the bowel by inserting a tube into the rectum. You are awake during this test and can drive yourself home.
		Yes
		No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
		No, for any other reason

57.	Within the past 12 months, have you had a blood stool test using a home kit? A doctor, nurse, or other health professional provides you a special kit or cards to use at home to determine whether the stool contains blood.
		Yes
		No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it
		No, for any other reason

Date completed:

	Who completed this form?
		Person named on front of this form
		Someone else,

If Someone Else, what is person’s relationship to the person named on the front of this form?
		Husband or wife
		Unmarried partner
		Mother, father, or guardian
		Son or daughter
		Other relative
		Not related

THANK YOU FOR COMPLETING THE QUSETIONNAIRE!

Please place this survey in the envelope provided to you and give it to the MEPS interviewer.

If the interviewer is no longer available, place the survey in the return envelope provided to you by the interviewer. If the envelope is missing, mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850

Data Year 2020         
20-233.F

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