Download:
pdf |
pdfMedicare Health Outcomes Survey
Questionnaire (English)
2011
Insert Cover Art (English)
OMB 0938-0701
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:
56. 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 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
© 2011 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.
OMB 0938-0701
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 .........................................
OMB 0938-0701
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
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
OMB 0938-0701
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
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
OMB 0938-0701
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
OMB 0938-0701
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
24. Other heart conditions, such as problems with heart valves or the
rhythm of your heartbeat ............................................................................
25. A stroke.......................................................................................................
OMB 0938-0701
No
Has a doctor ever told you that you had:
Yes
No
32. Diabetes, high blood sugar, or sugar in the urine .......................................
1
2
33. Any cancer (other than skin cancer) ...........................................................
1
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 (for
example, work, school, or housework)?
All of
the time
1
Most of
the time
2
Some of
the time
A little of
the time
3
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? ................
1
2
1
2
1
2
39. How much of the time in the past week did you feel depressed?
Rarely or none of the
time
1
OMB 0938-0701
Some or a little
of the time
2
Occasionally or a
moderate amount of
the time
3
Most or all of the
time
4
No
40. 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
41. 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
42. 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 43
No
ÎGo to Question 46
43. How much of a problem, if any, was the urine leakage for you?
1
2
3
A big problem
ÎGo to Question 44
A small problem ÎGo to Question 44
Not a problem
ÎGo to Question 46
44. Have you talked with your current doctor or other health provider about your urine leakage
problem?
1
2
Yes
No
45. 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
OMB 0938-0701
46. 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 47
No
ÎGo to Question 47
I had no visits in the past 12 months
ÎGo to Question 48
47. 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
48. 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
49. Did you fall in the past 12 months?
1
2
Yes
No
50. In the past 12 months, have you had a problem with balance or walking?
1
2
Yes
No
51. 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.
1
2
3
Yes
No
I had no visits in the past 12 months
OMB 0938-0701
52. 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
No
2
53. 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.
54. 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
55. In what year were you born? Please provide your year of birth only.
1
9
56. Are you male or female?
1
2
Male
Female
OMB 0938-0701
57. Are you of Hispanic or Latino origin or descent?
1
2
Yes, Hispanic or Latino
No, not Hispanic or Latino
58. How would you describe your race? Please mark one or more.
a
b
c
d
e
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
59. What is your current marital status?
1
2
3
4
5
Married
Divorced
Separated
Widowed
Never married
60. 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
61. 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
OMB 0938-0701
62. Who completed this survey form?
1
2
3
4
Person to whom survey was addressed
ÎGo to Question 64
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
63. What is the name of the person who completed this survey form? Please print clearly.
First Name
Last Name
64. 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.
OMB 0938-0701
“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.”
Insert Vendor Contact Information Here
| File Type | application/pdf |
| File Title | Medicare Health Outcomes Survey Instructions |
| Author | NCQA |
| File Modified | 2010-12-02 |
| File Created | 2010-12-02 |