Form #1 Form #1 Adult SAQ

2

Form Approved
OMB No. 0935-0118
Exp. Date XX/XX/20XX

010

Your Health and Health Opinions

Your opinion matters!

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 checking 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:

1 Yes

2 No Skip to Question 3

Next Question

This Booklet Should RUID: PID:

Be Completed By Name:

Version: DOB: Panel/ Round:

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).

When you have completed the booklet, please seal it with this label and place it in the envelope provided. Have it ready to give to your interviewer at his or her next visit.

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

Your responses will be kept confidential to the extent permitted by law, including AHRQ’s confidentiality statute, 42 USC 299c-3(c). That law requires that information collected for research conducted or supported by AHRQ that identifies individuals or establishments be used only for the purpose for which it was supplied unless you consent to the use of the information for another purpose. 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.

START HERE

Your Health Care

in the Last 12 Months

1. 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?

1 Yes

2 No Skip to Question 3

2. In the last 12 months, when you needed care right away how often did you get care as soon as you thought you needed?

1 Never

2 Sometimes

3 Usually

4 Always

3. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor’s office or clinic?

1 Yes

2 No Skip to Question 5

4. In the last 12 months, not counting the times you needed care right away, how often did you get an appointment for your health care at a doctor’s office or clinic as soon as you thought you needed?

1 Never

2 Sometimes

3 Usually

4 Always

5. 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?

0 None Skip to Question 13

1 1

2 2

3 3

4 4

5 5 to 9

6 10 or more

6.In the last 12 months, did you or a doctor believe you needed any care, tests, or treatment?

1 Yes

2 No Skip to Question 8

7.In the last 12 months, how often was it easy to get the care, tests, or treatment you or a doctor believed necessary?

1 Never

2 Sometimes

3 Usually

4 Always

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

1 Never

2 Sometimes

3 Usually

4 Always

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

1 Never

2 Sometimes

3 Usually

4 Always

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

1 Never

2 Sometimes

3 Usually

4 Always

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

1 Never

2 Sometimes

3 Usually

4 Always

12.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

1

2

3

4

5

6

7

8

9

10 Best health care possible

13.Do you currently smoke?

1 Yes

2 No Skip to Question 15

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

1 Yes

2 No

3 Had no visits in the last 12 months

15. In the last 2 years, has your blood pressure been checked by a doctor, nurse, or other health professional?

1 Yes

2 No

Getting Health Care

from a Specialist

When you answer the next questions, do not include dental visits.

16. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and others who specialize in one area of health care.

In the last 12 months, did you or a doctor think you needed to see a specialist?

1 Yes

2 No Skip to Question 18

17. In the last 12 months, how often was it easy to see a specialist that you needed to see?

1 Never

2 Sometimes

3 Usually

4 Always

General Health

18.In general, would you say your health is:

1 Excellent

2 Very good

3 Good

4 Fair

5 Poor

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

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

1 Yes, limited a lot

2 Yes, limited a little

3 No, not limited at all

20.Climbing several flights of stairs

1 Yes, limited a lot

2 Yes, limited a little

3 No, not limited at all

During the past 4 weeks how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

21.Accomplished less than you would like

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

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

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

During the past 4 weeks, how much of the time 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)?

23.Accomplished less than you would like

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

24.Did work or other activities less carefully than usual

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

25. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

1 Not at all

2 A little bit

3 Moderately

4 Quite a bit

5 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.

How much of the time during the past 4 weeks:

26.Have you felt calm and peaceful?

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

27.Did you have a lot of energy?

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

28.Have you felt downhearted and depressed?

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

29.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.)?

1 All of the time

2 Most of the time

3 Some of the time

4 A little of the time

5 None of the time

SF-12v2TM Health Survey © 1994, 2002 by QualityMetric Incorporated and

Medical Outcomes Trust. All Rights Reserved.

SF-12® a registered trademark of Medical Outcomes Trust.

(SF-12v2 Standard, US Version 2.0)

The following questions ask about how you have been feeling during the past 30 days. For each question, please place a check mark in the box that best describes how often you had this feeling.

All Most Some A little None

During the past 30 days, about how of the of the of the of the of the

often did you feel... time time time time time

30. ...nervous? 1 2 3 4 5

31. ...hopeless? 1 2 3 4 5

32. ...restless or fidgety? 1 2 3 4 5

33. ...so sad that nothing could 1 2 3 4 5
cheer you up?

34. ...that everything was an effort? 1 2 3 4 5

35. ...worthless? 1 2 3 4 5

The following two questions ask about how you have been feeling in the past 2 weeks.

Over the last 2 weeks, how often have Nearly More than

you been bothered by any of the every half the Several Not at

following problems? day days days all

36. Little interest or pleasure in doing things. 1 2 3 4

37. Feeling down, depressed, or hopeless. 1 2 3 4

Opinions about Health

For items 38-41, please check one of the boxes to indicate how strongly you agree or disagree for each statement. If you are uncertain, check the box for uncertain.

Disagree Disagree Agree Agree
strongly somewhat Uncertain somewhat strongly

38.I’m healthy enough that I really
don’t need health insurance. 1 2 3 4 5

39.Health insurance is not worth
the money it costs. 1 2 3 4 5

40.I’m more likely to take risks than
the average person. 1 2 3 4 5

41.I can overcome illness without help
from a medically trained person. 1 2 3 4 5

Date completed:

If this booklet was not completed by
the person named on the front, who completed it:

What is this person’s relationship to
the person named on the front:

Thank you for taking the time to complete this survey.

Remember to seal it and place it in the envelope provided.

PUBLICATION 10-228