Form #2 Attachment 23 -- HC Diabetes SAQ - Self

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

Attachment 23 -- HC Diabetes SAQ - Self

Diabetes Care SAQ

OMB: 0935-0118

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Form Approved

OMB #0935-0118

Exp. Date

Self 2013




Shape1


Shape2 A Survey About Your Diabetes Care


The care of people with diabetes is an important concern of the U.S. Department of Health and Human Services. Please take a few minutes to answer the following questions on the care you received for your diabetes. Your participation is voluntary and all of your answers will be kept confidential to the extent

permitted by law. If you have any questions about this survey, please call

Shape3 Alex Scott at 1-800-945-MEPS (6377).



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 Your 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.


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.




1. Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes?

MARK ONE.


Shape15 Yes ..........................................................

Please continue.


Shape16 No ...........................................................

Thank you for your time. This survey is complete.

3. Which of the following year(s) did a doctor or other health professional check your feet for any sores or irritations?

MARK ALL THAT APPLY.


Shape17 Shape18 Shape19 Shape20 During 2013 ...................................... During 2012 ...................................... During 2011...................................... Before 2011 ......................................

Shape21 Never ................................................


Shape22 Shape23 Shape24 Shape25 Shape26 2. During 2011, how many times did a doctor, nurse, or other health professional check your 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.)


Shape27 If you had this blood test, fill in

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


Shape28 Shape29 Shape30 Did not have A1C blood test ........... Don't know ...................................... Never ..............................................

4. Which of the following year(s) did you have an eye exam in which your pupils were dilated? This would have made you 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 you have your 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 you

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 your diabetes caused problems with your kidneys?


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


8. Has your diabetes caused problems

with your eyes that needed to be treated by an ophthalmologist?


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


9. Is your diabetes being treated by modifying your diet?


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


10. Is your diabetes being treated by medications taken by mouth?


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

11. Is your diabetes being treated with insulin injections?


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


12. During the last 12 months, have you learned how to take care of your diabetes?


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


13. Which of the following methods have you used to learn to take care of your diabetes? MARK ALL THAT APPLY.


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

Shape59 Talking to a doctor/health professional not in your 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 are you in taking care of your 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

If this survey was not completed by the person named on the front page, who completed the survey?



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

13-230




4

3

12345


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