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pdf Medicare Health Outcomes Survey Instructions
This survey asks about you and your health. Answer each question thinking about
yourself. Please take the time to complete this survey. Your answers are very
important to us. If you are unable to complete this survey, a family member or
“proxy” can fill out the survey about you.
Please return the survey with your answers in the enclosed postage-paid envelope.
Sample Questions:
¾ Answer the questions by putting an ‘X’ in the box next to the appropriate answer
category like this:
55. Are you male or female?
1
2
Male
Female
¾ Be sure to read all the answer choices given before marking a box with an ‘X.’
¾ You are sometimes told to answer some questions in this survey only when you have
answered a previous question. When this happens, you will see an italicized instruction
like the one below:
If you answered "yes" to question 33 above (that you have had cancer),
All information that would permit identification of any person who completes
this survey will be kept strictly confidential. This information will be used only
for the purposes of this study and will not be disclosed or released for any other
purposes without your permission.
If you have any questions or want to know more about the study, please call
[vendor name] at [toll-free number].
OMB 0938-0701 Version 02-1
© 2006 by the National Committee for Quality Assurance (NCQA). This survey instrument may not be reproduced or
transmitted in any form, electronic or mechanical, without the express written permission of NCQA. All rights reserved.
Items 1-9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.
Medicare Health Outcomes Survey
1.
In general, would you say your health is:
Excellent
1
2.
Very good
Good
2
Fair
3
4
Yes,
limited
a lot
a. Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf ....................
b. Climbing several flights of stairs....................................
Yes,
limited
a little
No, not
limited
at all
1
2
3
1
2
3
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?
No,
none
of the
time
a. Accomplished less than you would like......
b. Were limited in the kind of work or other
activities ........................................................
4.
5
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?
ACTIVITIES
3.
Poor
Yes,
a little
of the
time
Yes,
some
of the
time
Yes,
most
of the
time
Yes,
all of
the
time
1
2
3
4
5
1
2
3
4
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 any emotional problems (such as feeling
depressed or anxious)?
No,
none
of the
time
a. Accomplished less than you would like......
b. Didn't do work or other activities as
carefully as usual.........................................
© 2006 National Committee for Quality Assurance
Yes,
a little
of the
time
Yes,
some
of the
time
Yes,
most
of the
time
Yes,
all of
the
time
1
2
3
4
5
1
2
3
4
5
1
Medicare Health Outcomes Survey
5.
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
1
A little bit
Moderately
2
Quite a bit
3
Extremely
4
5
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.
6.
How much of the time during the past 4 weeks:
All
of the
time
a. Have you felt calm and
peaceful?.....................................
7.
Most
of the
time
A good
bit of
the time
Some
of the
time
A little
of the
time
None
of the
time
1
2
3
4
5
6
b. Did you have a lot of energy? .....
1
2
3
4
5
6
c. Have you felt downhearted
and blue? ....................................
1
2
3
4
5
6
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
1
Most of
the time
2
Some of
the time
3
A little of
the time
None of
the time
4
5
Now, we’d like to ask you some questions about how your health may have changed.
8.
Compared to one year ago, how would you rate your physical health in general now?
Much better
1
9.
Slightly better
2
About the
same
3
Slightly worse
4
Much worse
5
Compared to one year ago, how would you rate your emotional problems (such as
feeling anxious, depressed or irritable) in general now?
Much better
1
Slightly better
2
© 2006 National Committee for Quality Assurance
About the
same
3
Slightly worse
4
Much worse
5
2
Medicare Health Outcomes Survey
Earlier in the survey you were asked to indicate whether you have any limitations in your
activities. We are now going to ask a few additional questions in this area.
10. Because of a health or physical problem, do you have any difficulty doing the following
activities without special equipment or help from another person?
No, I do not
have difficulty
Yes, I have
difficulty
I am unable to
do this activity
a. Bathing ................................................
1
2
3
b. Dressing ..............................................
1
2
3
c. Eating ..................................................
1
2
3
d. Getting in or out of chairs ....................
1
2
3
e. Walking ...............................................
1
2
3
f. Using the toilet ....................................
1
2
3
These next questions ask about your physical and mental health during the past 30 days.
11. Now, thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good? (Please enter a
number between "0" and "30" days. If no days, please enter “0” days.)
days
12. Now, thinking about your mental health, which includes stress, depression, and problems
with emotions, for how many days during the past 30 days was your mental health not
good? (Please enter a number between "0" and "30" days. If no days, please enter “0”
days.)
days
13. During the past 30 days, for about how many days did poor physical or mental health
keep you from doing your usual activities, such as self-care, work, or recreation? (Please
enter a number between "0" and "30" days. If no days, please enter “0” days.)
days
© 2006 National Committee for Quality Assurance
3
Medicare Health Outcomes Survey
Now we are going to ask some questions about specific medical conditions.
14. During the past 4 weeks, how often have you had any of the following problems?
All of
the time
a. Chest pain or pressure
when you exercise .................
b. Chest pain or pressure
when resting...........................
Most of
the time
Some of
the time
A little of
the time
None of
the time
1
2
3
4
5
1
2
3
4
5
15. During the past 4 weeks, how often have you felt short of breath under the following
conditions?
All of
Most of
Some of A little of
None of
the time
the time
the time
the time
the time
a. When lying down flat ..............
1
2
3
4
5
1
2
3
4
5
c. When walking less than
one block................................
1
2
3
4
5
d. When climbing one flight
of stairs...................................
1
2
3
4
5
b. When sitting or resting ...........
16. During the past 4 weeks, how much of the time have you had any of the following
problems with your legs and feet?
All of
the time
Most of
the time
Some of
the time
A little of
the time
None of
the time
a. Numbness or loss of feeling
in your feet .............................
1
2
3
4
5
b. Tingling or burning
sensation in your feet
especially at night...................
1
2
3
4
5
c. Decreased ability to feel hot
or cold with your feet ..............
1
2
3
4
5
d. Sores or wounds on your
feet that did not heal...............
1
2
3
4
5
© 2006 National Committee for Quality Assurance
4
Medicare Health Outcomes Survey
17. During the past 4 weeks, how would you describe any arthritis pain you usually had?
None
1
Very Mild
2
Mild
3
Moderate
Severe
4
5
Yes
No
18. Can you see well enough to read newspaper print (with your glasses or
contacts if that's how you see best)?..........................................................
1
2
19. Can you hear most of the things people say (with a hearing aid if that's
how you hear best)? ...................................................................................
1
2
Has a doctor ever told you that you had:
Yes
20. Hypertension or high blood pressure..........................................................
1
2
21. Angina pectoris or coronary artery disease ................................................
1
2
22. Congestive heart failure..............................................................................
1
2
23. A myocardial infarction or heart attack .......................................................
1
2
1
2
1
2
26. Emphysema, or asthma, or COPD (chronic obstructive pulmonary
disease) ......................................................................................................
1
2
27. Crohn’s disease, ulcerative colitis, or inflammatory bowel
disease .......................................................................................................
1
2
28. Arthritis of the hip or knee...........................................................................
1
2
29. Arthritis of the hand or wrist ........................................................................
1
2
30. Osteoporosis, sometimes called thin or brittle bones .................................
1
2
31. Sciatica (pain or numbness that travels down your leg to below your
knee)...........................................................................................................
1
2
32. Diabetes, high blood sugar, or sugar in the urine .......................................
1
2
24. Other heart conditions, such as problems with heart valves or the
rhythm of your heartbeat ............................................................................
25. A stroke.......................................................................................................
© 2006 National Committee for Quality Assurance
No
5
Medicare Health Outcomes Survey
Has a doctor ever told you that you had:
Yes
33. Any cancer (other than skin cancer) ...........................................................
1
No
2
If you answered "yes" to question 33 above (that you have had cancer),
34. Are you currently under treatment for:
Yes
No
a. Colon or rectal cancer............................................................................
1
2
b. Lung cancer ...........................................................................................
1
2
c. Breast cancer.........................................................................................
1
2
d. Prostate cancer......................................................................................
1
2
35. In the past 4 weeks, how often has low back pain interfered with your usual daily activities
(work, school or housework)?
All of
the time
1
Most of
the time
2
Some of
the time
3
A little of
the time
None of
the time
4
5
Yes
36. In the past year, have you had 2 weeks or more during which you
felt sad, blue or depressed; or when you lost interest or pleasure in
things that you usually cared about or enjoyed? ....................................
37. In the past year, have you felt depressed or sad much of the time?......
38. Have you ever had 2 years or more in your life when you felt
depressed or sad most days, even if you felt okay sometimes? ............
© 2006 National Committee for Quality Assurance
No
1
2
1
2
1
2
6
Medicare Health Outcomes Survey
39. In general, compared to other people your age, would you say that your health is:
1
2
3
4
5
Excellent
Very good
Good
Fair
Poor
40. Do you now smoke every day, some days, or not at all?
1
2
3
4
Every day
Some days
Not at all
Don’t know
41. Many people experience problems with urinary incontinence, the leakage of urine. In the
past 6 months, have you accidentally leaked urine?
1
2
Yes
ÎGo to Question 42
No
ÎGo to Question 45
42. How much of a problem, if any, was the urine leakage for you?
1
2
3
A big problem
ÎGo to Question 43
A small problem ÎGo to Question 43
Not a problem
ÎGo to Question 45
43. Have you talked with your current doctor or other health provider about your urine leakage
problem?
1
2
Yes
No
44. There are many ways to treat urinary incontinence including bladder training, exercises,
medication and surgery. Have you received these or any other treatments for your current
urine leakage problem?
1
2
Yes
No
© 2006 National Committee for Quality Assurance
7
Medicare Health Outcomes Survey
45. In the past 12 months, did you talk with a doctor or other health provider about your level
of exercise or physical activity? For example, a doctor or other health provider may ask if
you exercise regularly or take part in physical exercise.
1
2
3
Yes
ÎGo to Question 46
No
ÎGo to Question 46
I had no visits in the past 12 months
ÎGo to Question 47
46. In the past 12 months, did a doctor or other health provider advise you to start, increase or
maintain your level of exercise or physical activity? For example, in order to improve your
health, your doctor or other health provider may advise you to start taking the stairs,
increase walking from 10 to 20 minutes every day or to maintain your current exercise
program.
1
2
Yes
No
47. A fall is when your body goes to the ground without being pushed. In the past 12 months,
did you talk with your doctor or other health provider about falling or problems with balance
or walking?
1
2
3
Yes
No
I had no visits in the past 12 months
48. Did you fall in the past 12 months?
1
2
Yes
No
49. In the past 12 months, have you had a problem with balance or walking?
1
2
Yes
No
50. Has your doctor or other health provider done these or anything else to help prevent falls or
treat problems with balance or walking? Some things they might do include:
• Suggest that you use a cane or walker.
• Check your blood pressure lying or standing.
• Suggest that you do an exercise or physical therapy program.
• Suggest a vision or hearing testing.
1
2
3
Yes
No
I had no visits in the past 12 months
© 2006 National Committee for Quality Assurance
8
Medicare Health Outcomes Survey
51. Have you ever had a bone density test to check for osteoporosis, sometimes thought of
as “brittle bones”? This test may have been done to your back, hip, wrist, heel or finger.
1
2
Yes
No
52. How much do you weigh in pounds (lbs.)?
01
90 lbs. or less
08
151–160 lbs.
15
221–230 lbs.
22
291–300 lbs.
02
91–100 lbs.
09
161–170 lbs.
16
231–240 lbs.
23
301–310 lbs.
03
101–110 lbs.
10
171–180 lbs.
17
241–250 lbs.
24
311–320 lbs.
04
111–120 lbs.
11
181–190 lbs.
18
251–260 lbs.
25
321 lbs. or more
05
121–130 lbs.
12
191–200 lbs.
19
261–270 lbs.
06
131–140 lbs.
13
201–210 lbs.
20
271–280 lbs.
07
141–150 lbs.
14
211–220 lbs.
21
281–290 lbs.
53. How tall are you without shoes on in feet (ft.) and inches (in.)? (If 1/2 in., please round up.)
01
5 ft. 00 in. or
less
05
5 ft. 04 in.
09
5 ft. 08 in.
13
6 ft. 00 in.
02
5 ft. 01 in.
06
5 ft. 05 in.
10
5 ft. 09 in.
14
6 ft. 01 in.
03
5 ft. 02 in.
07
5 ft. 06 in.
11
5 ft. 10 in.
15
6 ft. 02 in.
04
5 ft. 03 in.
08
5 ft. 07 in.
12
5 ft. 11 in.
16
6 ft. 03 in. or more
54. In what year were you born? Please provide your year of birth only. For example, if your
date of birth is January 1, 1935, please answer “1935.”
55. Are you male or female?
1
2
Male
Female
56. Are you of Hispanic or Latino origin or descent?
1
2
Yes, Hispanic or Latino
No, not Hispanic or Latino
© 2006 National Committee for Quality Assurance
9
Medicare Health Outcomes Survey
57. How would you describe your race? Please mark one or more.
a
b
c
d
e
f
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Another race
58. What is your current marital status?
1
2
3
4
5
Married
Divorced
Separated
Widowed
Never married
59. What is the highest grade or level of school that you have completed?
1
2
3
4
5
6
8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2 year degree
4 year college graduate
More than a 4 year college degree
60. Is the house or apartment you currently live in:
1
2
3
4
5
Owned or being bought by you
Owned or being bought by someone in your family other than you
Rented for money
Not owned and one in which you live without payment of rent
None of the above
© 2006 National Committee for Quality Assurance
10
Medicare Health Outcomes Survey
61. Who completed this survey form?
1
2
3
4
Person to whom survey was addressed
ÎGo to Question 63
Family member or relative of person to whom the survey was addressed
Friend of person to whom the survey was addressed
Professional caregiver of person to whom the survey was addressed
62. What is the name of the person who completed this survey form? Please print clearly.
First Name
Last Name
63. Which of the following categories best represents the combined income for all family
members in your household for the past 12 months?
01
02
03
04
05
06
07
08
09
10
Less than $5,000
$5,000–$9,999
$10,000–$19,999
$20,000–$29,999
$30,000–$39,999
$40,000–$49,999
$50,000–$79,999
$80,000–$99,999
$100,000 or more
Don’t know
YOU HAVE COMPLETED THE SURVEY. THANK YOU.
© 2006 National Committee for Quality Assurance
11
Medicare Health Outcomes Survey
“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information that does not display a valid OMB control number. The valid OMB control number for this
information collection is 0938-0701. The time required to complete this information collection is estimated
to average 20 minutes including the time to review instructions, search existing data resources, gather the
data needed, and complete and review the information collection. If you have comments concerning the
accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500
Security Boulevard, C3-16-27, Baltimore, Maryland 21244-1850.”
© 2006 National Committee for Quality Assurance
12
| File Type | application/pdf |
| File Title | Medicare Health Outcomes Survey Instructions |
| Author | NCQA |
| File Modified | 2006-05-05 |
| File Created | 2006-05-05 |