Form CMS-10203 Medicare HOS 2013 Questionnaire (English)

Medicare Health Outcomes Survey (HOS)
Questionnaire (English)

HOS 2.5 2013

Insert Cover Art (English)

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:
 Answer the questions by putting an „X‟ in the box next to the appropriate answer category like
this:
58. What is your sex?
1
2

Male
Female

 Be sure to read all the answer choices given before marking a box with an „X.‟
 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 36 above (that you have had cancer),
All information that would permit identification of any person who completes
this survey is protected by the Privacy Act and the Health Insurance Portability
and Accountability Act (HIPAA). This information will be used only for purposes
permitted by law and will not be disclosed or released for any other reason. 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

© 2013 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.

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Medicare Health Outcomes Survey
1.

In general, would you say your health is:
Excellent
1

2.

3.

4.

5.

Very good
2

Good

Fair

3

Poor

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?
Yes,
Yes,
No, not
limited
limited
limited
ACTIVITIES
a lot
a little
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

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,
Yes,
Yes,
Yes,
Yes,
none a little some
most
all of
of the of the of the of the
the
time
time
time
time
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

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,
Yes,
Yes,
Yes,
Yes,
none a little some
most
all of
of the of the of the of the
the
time
time
time
time
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

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

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A little bit
2

Moderately
3

Quite a bit
4

Extremely
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

7.

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

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

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Slightly better
2

About the
same
3

Slightly worse
4

Much worse
5

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

11. Because of a health or physical problem, do you have any difficulty doing the following activities?
No

Yes

I don’t do this
activity

a. Preparing meals .................................

1

2

3

b. Managing money................................

1

2

3

c. Taking medication as prescribed ........

1

2

3

These next questions ask about your physical and mental health during the past 30 days.
12. 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
13. 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
14. 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.

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days

Now we are going to ask some questions about specific medical conditions.
Yes

No

15. Are you blind or do you have serious difficulty seeing, even when
wearing glasses? .........................................................................................

1

2

16. Are you deaf or do you have serious difficulty hearing? ...............................

1

2

17. Because of a physical, mental or emotional condition, do you have
serious difficulty concentrating, remembering or making decisions? ............

1

2

18. Do you have serious difficulty walking or climbing stairs? ............................

1

2

19. Do you have difficulty dressing or bathing?..................................................

1

2

20. Because of a physical, mental or emotional condition, do you have
difficulty doing errands alone such as visiting a doctor‟s office or
shopping? ....................................................................................................

1

2

21. In the last month, how often did memory problems interfere with your daily activities?
Most days
Some days
Rarely
Every day
(5-6 days a
(2-4 days a
(once a week or
(7 days a week)
week)
week)
less)
Never
1

2

3

4

5

Has a doctor ever told you that you had:

Yes

22. Hypertension or high blood pressure ...........................................................

1

2

23. Angina pectoris or coronary artery disease ..................................................

1

2

24. Congestive heart failure ...............................................................................

1

2

25. A myocardial infarction or heart attack .........................................................

1

2

26. Other heart conditions, such as problems with heart valves or the
rhythm of your heartbeat..............................................................................

1

2

1

2

1

2

27. A stroke .......................................................................................................
28. Emphysema, or asthma, or COPD (chronic obstructive pulmonary
disease) .......................................................................................................

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No

Has a doctor ever told you that you had:
Yes
29. Crohn‟s disease, ulcerative colitis, or inflammatory bowel
disease ........................................................................................................ 1

2

30. Arthritis of the hip or knee ............................................................................

1

2

31. Arthritis of the hand or wrist .........................................................................

1

2

1

2

1

2

34. Diabetes, high blood sugar, or sugar in the urine .........................................

1

2

35. Depression ..................................................................................................

1

2

36. Any cancer (other than skin cancer) ............................................................

1

2

32. Osteoporosis, sometimes called thin or brittle bones ...................................
33. Sciatica (pain or numbness that travels down your leg to below your
knee) ...........................................................................................................

No

If you answered "yes" to question 36 above (that you have had cancer),
37. 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

38. In the past 7 days, how much did pain interfere with your day to day activities?
Not at all

A little bit

1

Somewhat

2

Quite a bit

3

Very much

4

5

39. In the past 7 days, how often did pain keep you from socializing with others?
Never

Rarely

1

Sometimes

2

Often

3

Always

4

5

40. In the past 7 days, how would you rate your pain on average?
Worst
imaginable pain

No pain
01

02

03

04

05

06

07

08

09

10

41. Over the past 2 weeks, how often have you been bothered by any of the following problems?
Not at all
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Several
days

More than
half the

Nearly
every day

days
a. Little interest or pleasure in
doing things ............................
b. Feeling down, depressed or
hopeless .................................

1

2

3

4

1

2

3

4

42. In general, compared to other people your age, would you say that your health is:
Excellent
1
2
3
4
5

Very good
Good
Fair
Poor

43. Do you now smoke every day, some days, or not at all?
Every day
1
2
3
4

Some days
Not at all
Don‟t know

44. Many people experience problems with urinary incontinence, the leakage of urine. In the past 6
months, have you accidentally leaked urine?
Yes
Go to Question 45
1
2

No

Go to Question 48

45. How much of a problem, if any, was the urine leakage for you?
A big problem
Go to Question 46
1
2
3

A small problem

Go to Question 46

Not a problem

Go to Question 48

46. Have you talked with your current doctor or other health provider about your urine leakage
problem?
Yes
1
2

No

47. 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?
Yes
1
2

No

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48. 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.
Yes
Go to Question 49
1
2
3

No

Go to Question 49

I had no visits in the past 12 months

Go to Question 50

49. 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.
Yes
1
2

No

50. 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?
Yes
1
2
3

No
I had no visits in the past 12 months

51. Did you fall in the past 12 months?
Yes
1
2

No

52. In the past 12 months, have you had a problem with balance or walking?
Yes
1
2

No

53. Has your doctor or other health provider done anything 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.
Yes
1
2
3

No
I had no visits in the past 12 months

54. 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.
Yes
1

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No

2

55. How much do you weigh in pounds (lbs.)?

lbs.

56. How tall are you without shoes on in feet (ft.) and inches (in.)? (If 1/2 in., please round up.)

ft.

in.

57. In what year were you born? Please provide your year of birth only.

1

9

58. What is your sex?
Male
1
2

Female

59. Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected)
No, not of Hispanic, Latino/a or Spanish origin
1
2
3
4
5

Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a or Spanish origin

60. What is your race? (One or more categories may be selected)
White
Korean
01
08
02
03
04
05
06
07

Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese

61. How well do you speak English?
Very well
1
Well
2
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09
10
11
12
13
14

Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

3
4

Not well
Not at all

62. What is your current marital status?
Married
1
2
3
4
5

Divorced
Separated
Widowed
Never married

63. What is the highest grade or level of school that you have completed?
8th grade or less
1
2
3
4
5
6

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

64. Do you live alone or with others?
Alone
1
2
3
4
5

With spouse/significant other
With children/other relatives
With non-relatives
With paid caregiver

65. Where do you live?
Independent house, apartment, condominium or mobile home Go to Question 66
1
2
3
4

Assisted living apartment or board and care home

Go to Question 66

Nursing home Go to Question 69
Other

Go to Question 69

66. Is the house or apartment you currently live in:
Owned or being bought by you
1
2
3
4
5

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

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67. Do you currently provide care for someone else in your home?
Yes
1
2

No

If you answered "yes" to question 67 above (that you currently provide care for someone else in
your home),
68. How often do you provide care? Please provide both Hours per day and Days per week.
Hours per day

Days per week

69. Do you have difficulty driving or getting a ride to places you need to go?
Always or almost always
1
2
3

Sometimes
Almost never or never

70. Who completed this survey form?
Person to whom survey was addressed
1
2
3
4

Go to Question 72

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

71. What is the name of the person who completed this survey form? Please print clearly.
First Name
Last Name
72. Which of the following categories best represents the combined income for all family members
in your household for the past 12 months?
Less than $5,000
01
02
03
04
05
06
07
08
09
10

$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

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YOU HAVE COMPLETED THE SURVEY. THANK YOU.
“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, C3-24-07, Baltimore, Maryland 21244-1850.”

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