Attachment 1 -- MEPS-HC SAQ Summary and Changes (022018)

Attachment 1 – MEPS-HC SAQ Summary and Changes

Questions added to the Adult Self-Administered Questionnaire (Adult SAQ)

A brief self-administered questionnaire (SAQ) will be used to collect self-reported (rather than through household proxy) information on health status, health opinions and preventive care services for adults 18 and older.

SAQ, Male and Female

Are you male or female? (age 18+)

Male

Female

What is your age? (age 18+)

Under 18

18 to 34

35 to 49

50 or older

In the past 12 months, has a doctor, nurse, or other health care professional given you advice about how to manage your weight, discussed weight loss goals with you, or referred you to a weight loss program to help with your diet and exercise? (age 35+)

Yes

No

In the last 12 months, has a doctor, nurse, or other health professional asked you how much and how often you drink alcohol? You may have answered in person, on paper, or on a computer? (age 35+)

Yes

No

In the last 12 months, have you had 5 or more drinks in one day? (A drink refers to one 12 oz. beer, 5 oz. glass of wine, or 1.5 oz. shot of hard liquor.) (age 35+)

Yes

No

In the last 12 months, has a doctor, nurse, or other health care professional advised you to cut back or stop drinking alcohol? (age 35+)

Yes

No

Has a doctor, nurse, or other health care professional ever asked you if you smoke or use tobacco? You may have answered in person, on paper, or on a computer. (age 35+)

Yes

No

In the last 12 months, on average, would you say you smoked cigarettes or used tobacco every day, some days, or not at all? (age 35+)

Every day

Some days

Not at all  If Not at all, go to

In the past 12 months, were you advised by a doctor, nurse, or other health care professional to quit smoking or quit using tobacco? (age 35+)

Yes

No

In the past 12 months, were you advised by a doctor, nurse, or other health care professional to take a medication to assist you with quitting smoking or using tobacco? Some medications that can be used are: nicotine gum, patch, nasal spray, inhaler, or prescription medicine. (age 35+)

Yes

No

In the past 12 months, has a doctor, nurse, or other health care professional discussed or provided methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or program to help stop smoking. (age 35+)

Yes

No

In the past 12 months, has your doctor, nurse, or other health care professional asked you about your mood, such as whether you are anxious or depressed? You may have answered in person, on paper, or on a computer. (age 35+)

Yes

No

Have you ever had a pneumonia shot? A pneumonia shot or pneumococcal vaccine is usually only given once or twice in a person's lifetime (age 50+)

Yes

No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it

No, for any other reason

Have you had the shingles vaccine? The vaccine is called Zostavax®, the zoster vaccine, or the shingles vaccine. The chicken pox virus causes shingles. The vaccine has been available since May 2006. (age 50+)

Yes

No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it

No, for any other reason

Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to prevent heart attack or stroke? (age 50+)

Yes

No

Have you had colon cancer or your entire colon removed? (age 50+)

Yes  If Yes, go to

No

Within the past 12 months, have you had a blood stool test using a home kit? A doctor, nurse, or other health professional provides you a special kit or cards to use at home to determine whether the stool contains blood. (age 50+)

Yes

No, it was offered to me by a doctor, nurse, or other health care professional but I chose not to receive it

No, for any other reason

Male SAQ

Have you had prostate cancer? (age 50+)

Yes Please turn to

No

Female SAQ

In the past 12 months, have you received counseling or information about birth control from a doctor or other medical care provider? (age 18+)

Yes

No

Have you had a hysterectomy or have you ever had cervical cancer? (age 35+)

Yes  If Yes, go to

No

About how old were you the last time you had a Pap test? (age 35+)

Younger than 35

35 to 44 years old

45 to 54 years old

55 to 64 years old

65 to 75 years old

75 or older

I have never had a Pap test

Have you had both breasts removed or have you ever had breast cancer? (age 50+)

Yes  If Yes, go to

No