Crosswalk

Current HOS Question
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.

Recommended Question
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. Your best estimate is fine.

Survey Notes
Revised question wording

__ 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.

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. Your best estimate is fine.

__ 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.

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. Your best estimate is fine.

__ Days

__ Days

16. Are you deaf or do you have serious
difficulty hearing?
1. Yes
2. No

16. Are you deaf or do you have serious
difficulty hearing, even with a hearing
aid?
1. Yes
2. No

Revised question wording

18. Do you have serious difficulty
walking or climbing stairs?
1. Yes
2. No

NA ******

Removed from survey

19. Do you have difficulty dressing or
bathing?
1. Yes
2. No

NA ******

Removed from survey

Revised question wording

Revised question wording

Current HOS Question
44. Many people experience problems
with urinary incontinence, the leakage of
urine. In the past 6 months, have you
accidentally leaked urine?
1. Yes
2. No

Recommended Question
42. Many people experience leakage of
urine, also called urinary incontinence. In
the past six months, have you
experienced leaking of urine?
1. Yes
2. No

Survey Notes
Replaced current Q44 with
new HEDIS measure of
urinary incontinence
question

45. How much of a problem, if any, was
the urine leakage for you?
1. A big problem
2. A small problem
3. Not a problem

43. During the past six months, how
much did leaking of urine make you
change your daily activities or interfere
with your sleep?
1. A lot
2. Somewhat
3. Not at all
44. Have you ever talked with a doctor,
nurse, or other health care provider
about leaking of urine?
1. Yes
2. No

Replaced current Q45 with
new HEDIS measure of
urinary incontinence
question

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?
1. Yes
2. No
NA ******

45. There are many ways to control or
manage the leaking of urine, including
bladder training exercises, medication
and surgery. Have you ever talked with a
doctor, nurse, or other health care
provider about any of these approaches?
1. Yes
2. No
53. During the past month, on average,
how many hours of actual sleep did you
get at night? (This may be different from
the number of hours you spent in bed.)
1. Less than 5 hours
2. 5 – 6 hours
3. 7 – 8 hours
4. 9 or more hours

Replaced current Q47 with
new HEDIS measure of
urinary incontinence
question

NA ******

54. During the past month, how would
you rate your overall sleep quality?
1. Very Good
2. Fairly Good
3. Fairly Bad
4. Very Bad

Added question to survey

57. In what year were you born? Please
provide your year of birth only
19__

NA ******

Removed from survey

46. Have you talked with your current
doctor or other health provider about
your urine leakage problem?
1. Yes
2. No

Replaced current Q46 with
new HEDIS measure of
urinary incontinence
question

Added question to survey

Current HOS Question
58. What is your sex?
1. Male
2. Female
65. Where do you live?
1. Independent house, apartment,
condominium or mobile home
2. Assisted living apartment or board and
care home
3. Nursing home
4. Other

Recommended Question
57. Are you male or female?
1. Male
2. Female
64. Where do you live?
1. House, apartment, condominium or
mobile home
2. Assisted living or board and care home
3. Nursing home
4. Other

Survey Notes
Revised question wording

67. Do you currently provide care for
someone else in your home?
1. Yes
2. No

NA ******

Removed from survey

68. During the past week, how many
days did you provide at least some care?
1. No care provided in the last week
2. 1 or 2 days
3. 3 or 4 days
4. 5 or 6 days
5. 7 days (every day)

NA ******

Removed from survey

69. Do you have difficulty getting to
places you need to go (either by driving
or by getting a ride)?
1. Always or almost always
2. Sometimes
3. Almost never or never

NA ******

Removed from survey

71. What is the name of the person who
completed this survey form? Please print
clearly.
First Name ___________
Last Name ___________

67. If you completed the survey for
someone else, please fill in your name.
DO NOT complete this question if you
completed the survey for yourself. Please
print clearly.
First Name ___________
Last Name ___________

Revised question wording

Revised response category
wording