CMS-10203 EGM HOS Modified Questionnaire English

Medicare Health Outcomes Survey- Modified Instructions
This survey asks about your health, feelings, and ability to do daily activities. Please take the
time to complete this survey. Your answers are very important to us. If you need help to
complete this survey, a family member or a friend may fill out the survey about your health. If
a family member or a friend is NOT available, please ask your nurse or other health
professional to help.
h Answer the questions by putting an 'X' in the box next to the appropriate answer category like
this:
49. Are you male or female?

:

Male

… Female

h Be sure to read all the answer choices given before marking a box with an 'X.'
h You may find some of the questions to be personal. It is important that you answer EVERY
question on this survey. However, you do not have to answer a question if you do not want to. If
you are unsure of the answer to a question or that the question applies to you, just choose the
BEST available answer.
Please complete the survey within two weeks and return it in the enclosed postage-paid
envelope.
IF YOU ARE FILLING OUT THIS SURVEY FOR SOMEONE ELSE
Please answer every question the way you believe best describes that person's health,
feelings, and ability to do daily activities. Answer each question the way you think the
person you are helping would answer about him or herself.
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
DataStat, Inc. toll-free at 1-877-455-3387.
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, 6-13: The VR-12 Health Survey item content was developed and modified from a 36-item
health survey

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Medicare Health Outcomes Survey- Modified
1. In general, would you say your health is:
Excellent
1

Very good

2

Good
3

Fair
4

Poor
5

2. How much difficulty, if any, do you have lifting or carrying objects as heavy as 10 pounds, such
as a sack of potatoes?
No difficulty at
all
1

A little difficulty

2

Some
difficulty
3

A lot of difficulty
4

Not able to
do it
5

3. How much difficulty, if any, do you have walking a quarter of a mile-that is about 2 or 3 blocks?
No difficulty at
all
1

A little difficulty

2

Some
difficulty
3

A lot of difficulty
4

Not able to
do it
5

4. 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

1

2

3

f. Using the toilet

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5. Do you receive help from another person with any of these activities?
Yes, I receive
help

No, I do not
receive help

I do not 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

1

2

3

f. Using the toilet

6. 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?

Yes,
limited
a lot

ACTIVITIES

Yes,
limited
a little

No, not
limited
at all

a. Moderate activities, such as
moving a table, pushing a
vacuum cleaner, bowling, or
playing golf

1

2

3

b. Climbing several flights of
stairs

1

2

3

7. 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

Yes, a
little of
the time

Yes,
some of
the time

Yes,
most of
the time

Yes, all
of the
time

a. Accomplished less than you
would like

1

2

3

4

5

b. Were limited in the kind of
work or other activities

1

2

3

4

5

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8. During the past 4 weeks, have you had any of the following problems with your regular daily
activities as a result of any emotional problems (such as feeling depressed or anxious)?
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

a. Accomplished less than you
would like

1

2

3

4

5

b. Didn't do work or other
activities as carefully as
usual

1

2

3

4

5

9. During the past 4 weeks, how much did pain interfere with your normal work (including both
work outside the home and house)?
Not at all
1

A little bit
2

Moderately

3

Quite a bit

4

Extremely

5

10. These questions are about how you feel and how things have been with you during the past
four 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...

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

a. have you felt calm and
peaceful?

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

11. 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

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Most of
the time
2

Some of
the time
3

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A little of
the time
4

None of
the time
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12. Now we'd like to ask you some questions about how your health may have changed.
Compared to one year ago, how would you rate your physical health in general now?
Much
better
1

Slightly
better
2

About the
same

3

Slightly
worse

4

Much
worse

5

13. 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

About the
same

3

Slightly
worse

4

Much
worse

5

14. Do you experience memory loss that interferes with daily activities?

… Yes
2… No
1

15. How often, if ever, do you have difficulty controlling urination (bladder accidents)?
Never
1

Less than once
a week
2

Once a week
or more often

3

Daily

4

Catheter
5

16. Who completed this survey form?

… Medicare Participant Î STOP HERE
2… Family member, relative,
1

or friend of Medicare Participant Î Go to Question 17
3

… Nurse or other health professional Î Go to Question 17

17. What was the reason you filled out this survey for someone else? (Please answer ALL that
apply.)

… Physical problems
2… Memory loss of mental problems
3… Unable to speak or read English
4… Person not available
5… Other
1

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18. How did you help complete this survey? (Please answer ALL that apply.)

… Read the questions to the person
… Wrote down the person's answers
3… Answered the questions based on my experience with the person
4… Used medical records to fill out the survey
5… Translated the survey questions
6… Other
1
2

FOR PROFESSIONAL STAFF (CAREGIVERS) ONLY
19. Which of the following best describes your position? (Please choose one answer.)

… Home Health Aide, Personal Care Attendant, or Certified Nursing Assistant
2… Nurse (RN, LPN, or NP)
3… Social Worker or Case Manager
4… Adult Foster Care/ Adult Day Care/ Assisted Living/ Residential Care Staff
5… Interpreter
6… Other
1

YOU HAVE COMPLETED THE SURVEY. THANK YOU.

When you are done, please use the enclosed prepaid envelope to mail the questionnaire to:
DataStat, Inc. 3975 Research Park Drive Ann Arbor, MI 48108

"According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays 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."

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