Form Attachment 18 Attachment 18 Attachment 18 HC Adult SAQ

3490
Form Approved
OMB# 0935-0118
Exp. Date 12/31/2018

2017

Understanding how people feel about their health and health care is an important goal of MEPS.
Please take a few minutes to answer the questions in this booklet.

Survey Instructions
 Please answer every question by marking one box "." If you are unsure about how to answer a question,
please give the best answer you can.

 You are sometimes told to skip over some questions in this survey. When this happens you will see
arrows that tell you what questions to answer next, like this:

Yes
No  If No, go to 3


Next Question
 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 booklet, please call Alex Scott at 1-800-945-MEPS (6377).

 Store your completed booklet in the envelope provided. Have it ready to give to your interviewer at his or her
next visit.

This Booklet
Should Be
Completed By 

REGION:

RUID:

PID:

NAME:

/

DOB:
MONTH

/
DAY

YEAR

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 7 minutes per response, the estimated time required to
complete the survey. An agency may not conduct or sponsor, and a 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, 5600 Fishers
Lane, Room #07W42, Rockville, MD 20857.

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

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General Health
1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
2. 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?
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
Yes, limited a lot
Yes, limited a little
No, not limited at all
b. Climbing several flights of stairs
Yes, limited a lot
Yes, limited a little
No, not limited at all
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?
a. Accomplished less than you would like as a result of your physical health
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
b. Were limited in the kind of work or other activities as a result of your physical health
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
"VR-12: How to create VR-12 scales and PCS/MCS summaries” © 2014 by Trustees of Boston University. All Rights Reserved.
(Questions concerning the VR-12 can be directed to Professor Lewis E. Kazis, Boston University e-mail: [email protected])

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4. 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)?
a. Accomplished less than you would like as a result of any emotional problems
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
b. Didn't do work or other activities as carefully as usual as a result of any emotional problems
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
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
A little bit
Moderately
Quite a bit
Extremely

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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:
a. Have you felt calm and peaceful?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
b. Did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
c. Have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

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7. 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
Most of the time
Some of the time
A little of the time
None of the time
8. The following questions ask about how you have been feeling during the past 30 days. For each
question, please mark the box that best describes how often you had this feeling.
During the past 30 days,
about how often did you feel...

All of the
time

Most of the
time

Some of the A little of the None of the
time
time
time

a. nervous?.......................................
b. hopeless?.....................................
c. restless or fidgety?........................
d. so sad that nothing could cheer
you up?.........................................
e. that everything was an effort?.......
f. worthless?.....................................
9. The following two questions ask about how you have been feeling in the past 2 weeks.
Over the last 2 weeks, how often have you
been bothered by any of the following
problems?

Nearly
every day

a. Little interest or pleasure in doing things..........
b. Feeling down, depressed, or hopeless.............

5

More than
half the days Several days

Not at all

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Opinions About Health
10. For the four statements below, please mark one of the boxes to indicate how strongly you agree or
disagree for each statement. If you are uncertain, mark the box for uncertain.
Disagree
strongly

Disagree
somewhat

Uncertain

Agree
somewhat

Agree
strongly

a. I'm healthy enough that I really don't
need health insurance.........................
b. Health insurance is not worth the
money it costs.....................................
c. I'm more likely to take risks than the
average person...................................
d. I can overcome illness without help
from a medically trained person..........

Your Health Care in the Last 12 Months
These questions ask about your own health care. Do not include care you got when you stayed
overnight in a hospital. Do not include the times you went for dental care visits.
11. In the last 12 months, did you have an illness, injury, or condition that needed care right away in
a clinic, emergency room, or doctor’s office?
Yes
No  If No, go to 13


12. In the last 12 months, when you needed care right away, how often did you get care as soon as
you thought you needed?
Never
Sometimes
Usually
Always
13. In the last 12 months, did you make any appointments for a check-up or routine care at a
doctor’s office or clinic?
Yes
No  If No, go to 15


If Yes, go to 14

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14. In the last 12 months, how often did you get an appointment for a check-up or routine care at a
doctor’s office or clinic as soon as you needed?
Never
Sometimes
Usually
Always
15. In the last 12 months, not counting the times you went to an emergency room, how many times
did you go to a doctor’s office or clinic to get health care for yourself?
None  If None, go to 26
1 time
2
3
4
5-9
10 or more times
16. Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best
health care possible, what number would you use to rate all your health care in the last 12
months?
0 Worst health care possible
1
2
3
4
5
6
7
8
9
10 Best health care possible

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17. In the last 12 months, did a doctor or other health provider give you instructions about what to do
about a specific illness or health condition?
Yes
No  If No, go to 20


18. In the last 12 months, how often were these instructions easy to understand?
Never
Sometimes
Usually
Always
19. In the last 12 months, how often did doctors or other health providers ask you to describe how you
were going to follow these instructions?
Never
Sometimes
Usually
Always
20. In the last 12 months, did you have to fill out or sign any forms at a doctor’s or other health
provider’s office?
Yes
No  If No, go to 22


21. In the last 12 months, how often were you offered help in filling out a form at the doctor’s or other
health provider’s office?
Never
Sometimes
Usually
Always

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22. In the last 12 months, how often did doctors or other health professionals explain things in a way
that was easy to understand?
Never
Sometimes
Usually
Always
23. In the last 12 months, how often did doctors or other health professionals listen carefully to you?
Never
Sometimes
Usually
Always
24. In the last 12 months, how often did doctors or other health professionals show respect for what
you had to say?
Never
Sometimes
Usually
Always
25. In the last 12 months, how often did doctors or other health professionals spend enough time with
you?
Never
Sometimes
Usually
Always
26. Do you currently smoke?
Yes
No  If No, go to the top of the next page


27. In the last 12 months, did a doctor advise you to quit smoking?
Yes
No
Had no visits in the last 12 months

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Getting Health Care from Specialists
When you answer the next questions, do not include dental visits or care you got when you stayed
overnight in a hospital.
28. Specialists are doctors like surgeons, heart doctors, allergy doctors, skin doctors, and other
doctors who specialize in one area of health care. In the last 12 months, did you make any
appointments to see a specialist?
Yes
No  If No, please go to the “Date completed” boxes below


29. In the last 12 months, how often did you get an appointment to see a specialist as soon as you
needed?
Never
Sometimes
Usually
Always

Date completed:

Month

Day

Year

Who completed this form?
Person named on front of this form
Someone else,

If Someone Else, what is person’s relationship to the person named on the front of this form?
Husband or wife
Unmarried partner
Mother, father, or guardian
Son or daughter
Other relative
Not related

Thank you for taking the time to complete this survey.
Remember to store it in the envelope provided.

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