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MEPS Home Medical Expenditure Panel Survey
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Form Approved
OMB #0935-0118
Exp. Date 12/31/2018

Proxy 2017

Medical Expenditure Panel Survey (MEPS)

A Survey About Diabetes Care

The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. We would appreciate it if you would take a few minutes to answer the following questions on the care your family member received for his or her diabetes. Your participation is voluntary and all of the answers will be kept confidential to the extent permitted by law. 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, return it to your interviewer.

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. 299-c3( 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 3 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.




Department of Health and Human Services (DHHS) logo

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



A Survey About Diabetes Care

Instructions:  Answer each question by checking one box sample check box with check mark or filling in a number when necessary. If you are unsure about how to answer a question, please give the best answer you can. In the questions below, “(NAME)” refers to the person listed in the box on the front page.

A health professional could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.

1.
Has (NAME) ever been told by a doctor or other health professional that he/she has diabetes or sugar diabetes? (CHECK ONE)
  empty check box Yes Please continue.
  empty check box No Thank you for your time. This survey is complete.

2.
During 2016, how many times did a doctor, nurse, or other health professional check (NAME)’s blood for glycosylated hemoglobin or “hemoglobin A-one-C?”  (A1C is a blood test to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor’s office although a home kit containing materials for one or two tests is now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis, and needs supplies of disposable test strips.)
    If (NAME) had this blood test, fill in NUMBER OF TIMES
  empty check box Did not have A1C blood test
  empty check box Don’t know
  empty check box Never

3.
Which of the following year(s) did a doctor or other health professional check (NAME)’s feet for any sores or irritations? (CHECK ALL THAT APPLY)
  empty check box During 2017
  empty check box During 2016
  empty check box During 2015
  empty check box Before 2015
  empty check box Never

4.
Which of the following year(s) did (NAME) have an eye exam in which his/her pupils were dilated? This would have made (NAME) temporarily sensitive to bright light. (CHECK ALL THAT APPLY)
  empty check box During 2017
  empty check box During 2016
  empty check box During 2015
  empty check box Before 2015
  empty check box Never

5.
Which of the following year(s) did (NAME) have his/her blood cholesterol checked? (CHECK ALL THAT APPLY)
  empty check box During 2017
  empty check box During 2016
  empty check box During 2015
  empty check box Before 2015
  empty check box Never

6.
Which of the following year(s) did (NAME) get a flu vaccination (shot or nasal spray)? (CHECK ALL THAT APPLY)
  empty check box During 2017
  empty check box During 2016
  empty check box During 2015
  empty check box Before 2015
  empty check box Never

7.
Has (NAME)’s diabetes caused problems with his/her kidneys?
  empty check box Yes
  empty check box No

8.
Has (NAME)’s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist?
  empty check box Yes
  empty check box No

9.
Is (NAME)’s diabetes being treated by modifying his/her diet?
  empty check box Yes
  empty check box No

10.
Is (NAME)’s diabetes being treated by medications taken by mouth?
  empty check box Yes
  empty check box No

11.
Is (NAME)’s diabetes being treated with insulin injections?
  empty check box Yes
  empty check box No

12.
During the last 12 months, has (NAME) learned how to take care of his/her diabetes?
  empty check box Yes
empty check box No Go to Question 14

13.
Which of the following methods has (NAME) used to learn to take care of his/her diabetes? (CHECK ALL THAT APPLY)
  empty check box Talking to a doctor/health professional within his/her primary care practice
  empty check box Talking to a doctor/health professional not in his/her primary care practice
  empty check box Telephone call with a health professional
  empty check box Reading about it on the Internet
  empty check box Taking a group class
  empty check box Other (specify)

14.
How confident is (NAME) in taking care of his/her diabetes?
  empty check box Not confident at all
  empty check box Somewhat confident
  empty check box Confident
  empty check box Very confident
  empty check box Refused
  empty check box Don’t know

Thank you for taking the time to complete this important survey.

Please remember to return it to your interviewer.

Date completed _________________________________

Who completed the survey for the person named on the front page?

____________________________________________________________________________________

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?

____________________________________________________________________________________

Data Year 2016
17-231

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