SEARCH Study Quality of Care Survey- Young Adult Version

This survey asks questions about your experiences with health care and
how you take care of diabetes on your own. There are no right or wrong
answers and all of the information you provide will be kept confidential.
Your answers will help us learn more about the quality of health care
patients and their families receive for diabetes.
HEALTH INSURANCE
1.

Have you had health insurance continuously during the past 12 months?
1

† Yes 2† No

If no, for how many months were you not covered by health insurance?
_______months.

YOUR HEALTH CARE IN THE LAST 12 MONTHS
The next questions ask about your health care in general. Do not include care you got
when you stayed overnight in a hospital. Do not include the times you went for dental
care visits.

2.

In the last 12 months, how much of a problem, if any, was it to get the care, tests,
or treatment you or a doctor believed necessary?

†
†
3
†
1
2

A big problem
A small problem
Not a problem

3.

In the last 12 months, has there been a time when you thought you should get care
but did not receive it?
1
† Yes
2
† No

4.

How much of a problem is the cost of health care for you (including paying for
health insurance premiums and co-payments for doctor’s office visits,
medications, and medical supplies)?

†
2
†
3
†
1

A big problem
A small problem
Not a problem

SEARCH 3 Cohort Study - Quality of Care Survey – Young Adult Version 11-01-10

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PRESCRIPTION MEDICATIONS

5.

In the last 12 months, how much of a problem, if any, was it to get your
prescription medicine and medical supplies?

†
†
3
†
1
2

A big problem
A small problem
Not a problem

EXPERIENCES WITH CARE
_______________________________________________________________________
6.

In the last 12 months, how often did you have a hard time speaking with or
understanding your doctors or other health providers because they spoke different
languages?

†
†
3
†
4
†
1
2

7.

Never
Sometimes
Usually
Always

An interpreter is someone who repeats or signs what one person says in a
language used by another person.
In the last 12 months, did you need an interpreter to help you speak with your
doctors or other health providers?
1
2

8.

†
†

Yes
No Î (If No, go to Question 9)

In the last 12 months, when you needed an interpreter to help you speak with your
doctors or other health providers, how often did you get one?

†
†
3
†
4
†
1
2

Never
Sometimes
Usually
Always

SEARCH 3 Cohort Study - Quality of Care Survey – Young Adult Version 11-01-10

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HEALTH CARE DECISIONS
___________________________________________________________________________
We want to know how you, your doctors and other health providers make decisions
about your health care.

9.

In the last 12 months, were any decisions made about your health care?

†
†

1
2

Yes
No Î (If No, go to Question 11)

10. When decisions were made in the last 12 months, how often did your doctors or
other health providers:
Never Sometimes Usually Always
10a. Offer you choices about your health
care?

1

†

2

†

3

†

4

†

10b. Discuss with you the good and bad
things about each of the different
choices for your health care?

1

†

2

†

3

†

4

†

10c. Ask you to tell them what choices you
prefer?

1

†

2

†

3

†

4

†

10d. Involve you as much as you wanted?

1

†

2

†

3

†

4

†

YOUR PERSONAL DOCTOR OR NURSE
11.

A personal doctor or nurse is the health provider who knows you best. This can be
a general doctor, a specialist doctor, a nurse practitioner, or a physician assistant.
Do you have one person you think of as your personal doctor or nurse? If you
have more than one personal doctor or nurse, choose the person you see most
often.

†Yes
†No Î

1
2

(If No, go to Question 13)

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12.

Using any number from 0 to 10 where 0 is the worst personal doctor or nurse
possible and 10 is the best personal doctor or nurse possible, what number would
you use to rate your personal doctor or nurse?

†0

†1

†2

†3

†4

†5

†6

†7

†8

†9

Worst
personal
doctor or
nurse
possible

†10
Best
personal
doctor or
nurse
possible

13. 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

†1

†2

†3

†4

†5

†6

†7

Worst
health
care
possible

14.

†8

†9

†10
Best
health
care
possible

In general, how would you rate your overall health now?

†Excellent
†Very Good
3
†Good
4
†Fair
5
†Poor
1
2

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HEALTH CARE FOR DIABETES

15.

For the next set of items, please indicate if your doctor or other health provider
has talked to you, about the following:
a. What to do for low blood sugar?
b. What to do for high blood sugar?
c. Appropriate physical activity for you?
d. Dietary guidelines for diabetes?
e. What a target blood sugar is for you?
f. How to adjust your insulin or diabetes
medication when you are sick?

g. Psychological issues you and your
family may face with regard to
having diabetes?
h. Who you can go to for general
information about diabetes?

† Yes
1† Yes
1† Yes
1† Yes
1† Yes
1† Yes
1

† No
2† No
2† No
2† No
2† No
2† No
2

† Unsure
3† Unsure
3† Unsure
3† Unsure
3† Unsure
3† Unsure /
3

no diabetes
medications
prescribed
1

† Yes

2

† No

3

† Unsure

1

† Yes

2

† No

3

† Unsure

16.

A test for hemoglobin A1C ("A one C") measures the average level of blood sugar
over the past three months. About how many times in the past 12 months has a
doctor or other health provider checked your hemoglobin A1C?
1† None
2† Once
3† Twice
4† Three or more times
5† Don’t know/ Not sure

17.

What A1C do you want to have?
___.___ (write in number)

† Don’t know/ Not sure

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18.

During the past 12 months, how often has your blood pressure been checked
during visits to your doctor’s office?

† Every visit
2† Most visits
3† At least once
4† Never
5† Don’t know/ Not sure
1

19.

When was the last time you had an eye exam by an eye specialist in which your
pupils were dilated (drops in your eyes that make eyes temporarily sensitive to
bright light) or a diabetes eye exam?

† In the past year
2† More than a year but less than 2 years
3† 2 – 5 years
4† More than 5 years
5† Never
6† Don’t know/Not sure
1

20.

When was the last time you had a urine test at the doctor’s office to check on your
kidney functioning?

† In the past year
2† More than a year but less than 2 years
3† 2 – 5 years
4† More than 5 years
5† Never
6† Don’t know/Not sure
1

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21.

When was the last time your doctor took a sample of your blood to test for
cholesterol or the amount of fat in your blood?

† In the past year
2† More than a year but less than 2 years
3† 2 – 5 years
4† More than 5 years
5† Never
6† Don’t know/Not sure
1

Thank you for completing this survey. We appreciate your participation
in this important study!

SEARCH 3 Cohort Study - Quality of Care Survey – Young Adult Version 11-01-10

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FOR STUDY USE ONLY
Date
Completed
Date
Reviewed
Date
Entered

Month

Month

Month

Day

Day

Day

Year

Year

Year

SEARCH 3 Cohort Study - Quality of Care Survey – Young Adult Version 11-01-10

Completer
Code
Reviewer
Code
Data Entry
Code

9