Form #1 Form #1 Attachment 22 -- HC Diabetes SAQ - Proxy

Medical Expenditure Panel Survey Household Component and Medical Provider Component (MEPS-HC and MEPS-MPC through 2009)

Attachment 22 -- HC Diabetes SAQ - Proxy

Diabetes Care SAQ

OMB: 0935-0118

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Form Approved

OMB #0935-0118

Exp. Date

Proxy 2013




Shape1


Shape2 A Survey About Diabetes Care


The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. We would appreciate it if you would take a few minutes to answer the following questions on the care your family member received for his or her diabetes. Your participation is voluntary and all of the answers will

be kept confidential to the extent permitted by law. If you have any questions about this survey, please call Alex Scott at 1-800-945-MEPS (6377).



Shape3 This survey should

be completed by NAME:






DOB:

/ /

MONTH DAY YEAR


PID:


1

12345

Shape5 Shape4 Shape6 Shape7 Shape8 Shape9 Shape10 Shape11


RUID:




Shape12 Shape13 When you have completed the survey, please fold it, seal it with this label, and place it in the envelope provided.





This survey is authorized under 42 U.S.C. 299a. The confidentiality of your responses to this survey is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed unless you have consented to that disclosure. Public reporting burden for this collection of information

is estimated to average 3 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a

Shape14 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.



The Agency for Healthcare Research and Quality and The Centers for Disease Control and Prev ention of the U.S. Department of Health and Human Services

A Survey About Diabetes Care


Instructions: Answer each question by marking one box or filling in a number when necessary. If you are unsure about how to answer a question, please give the best answer you can. In the questions below, "(NAME)" refers to the person listed in the box on the front page.


A health professional could be a general doctor, a specialist doctor, a nurse practitioner, a physician assistant, a nurse, or anyone else you would see for health care.



Shape15 Shape16 Shape17 Shape18 Shape19 1. Has (NAME) ever been told by a doctor or other health professional that he/she has diabetes or sugar diabetes?

MARK ONE.

Shape20 Yes ..........................................................

Please continue.


Shape21 No ...........................................................

Thank you for your time. This survey is complete.



2. During 2011, how many times did a doctor, nurse, or other health professional check (NAME)'s blood for glycosylated hemoglobin or "hemoglobin A-one-C"?

(A1C is a blood test to monitor the glucose level of diabetes over a period of several months. The A1C test is usually done in a lab, hospital, or doctor's office although a home kit containing materials for one or two tests is now available. The A1C test is not the same as a Home Glucose Monitoring test which is used at home to monitor glucose levels on a daily or weekly basis,

and needs supplies of disposable test strips.)


Shape22 If (NAME) had this blood test, fill in

NUMBER OF TIMES ......................


Shape23 Shape24 Shape25 Did not have A1C blood test ........... Don't know ...................................... Never ..............................................

3. Which of the following year(s) did a doctor

or other health professional check (NAME)'s feet for any sores or irritations?

MARK ALL THAT APPLY.

Shape26 Shape27 Shape28 Shape29 Shape30 During 2013 ...................................... During 2012 ...................................... During 2011 ...................................... Before 2011 ...................................... Never ................................................


4. Which of the following year(s) did (NAME)

have an eye exam in which his/her pupils

were dilated? This would have made (NAME)

temporarily sensitive to bright light. MARK ALL THAT APPLY.

Shape31 Shape32 Shape33 Shape34 Shape35 During 2013 ...................................... During 2012 ...................................... During 2011 ...................................... Before 2011 ...................................... Never ................................................


5. Which of the following year(s) did (NAME) have his/her blood cholesterol checked? MARK ALL THAT APPLY.

Shape36 Shape37 Shape38 Shape39 Shape40 During 2013 ...................................... During 2012 ...................................... During 2011 ...................................... Before 2011 ...................................... Never ................................................

6. Which of the following year(s) did (NAME) get a flu vaccination (shot or nasal spray)? MARK ALL THAT APPLY.

Shape41 Shape42 Shape43 Shape44 Shape45 During 2013 ........................................... During 2012 ........................................... During 2011 ........................................... Before 2011 ........................................... Never .....................................................

7. Has (NAME)'s diabetes caused problems with his/her kidneys?


Shape46 Shape47 Yes ......................................................... No ..........................................................


8. Has (NAME)'s diabetes caused problems with his/her eyes that needed to be treated by an ophthalmologist?


Shape48 Shape49 Yes ......................................................... No ..........................................................


9. Is (NAME)'s diabetes being treated by modifying his/her diet?


Shape50 Shape51 Yes ......................................................... No ..........................................................


10. Is (NAME)'s diabetes being treated by medications taken by mouth?


Shape52 Shape53 Yes ......................................................... No ..........................................................

11. Is (NAME)'s diabetes being treated with insulin injections?


Shape54 Shape55 Yes ......................................................... No ..........................................................


12. During the last 12 months, has (NAME)

learned how to take care of his/her diabetes?


Shape56 Shape57 Yes ......................................................... No (Skip to Q 14)....................................


13. Which of the following methods has (NAME) used to learn to take care of his/her diabetes? MARK ALL THAT APPLY.

Shape58 Talking to a doctor/health professional within his/her primary care practice ........

Shape59 Talking to a doctor/health professional not in his/her primary care practice ........

Telephone call with a

Shape60 Shape61 Shape62 Shape63 health professional ................................. Reading about it on the Internet ............ Taking a group class .............................. Other (specify)


14. How confident is (NAME) in taking care of his/her diabetes?


Shape64 Shape65 Shape66 Shape67 Shape68 Not confident at all ................................. Somewhat confident .............................. Confident ............................................... Very confident ....................................... Refused .................................................

Shape69 Don't know ............................................

Shape70 Shape71 Shape72 Shape73 Shape74 Shape75

Thank you for taking the time to complete this important survey.

Please remember to fold it, seal it, and place it in the envelope provided.


Shape76 Shape77 Shape78 Date completed: MONTH DAY YEAR


Who completed the survey for the person named on the front page?



Shape79 What is this person's relationship to the person named on the front page?



Shape80 Shape81 What is the reason the person named on the front page did not complete the survey himself/herself?





























































Data Year 2012

13-231




4

3

12345


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