Form 106a Attachment 106a.REV_Female PSAQ with Mental Health Conte

Draft
Form Approved
OMB#
Exp. Date

2020

There are a lot of clinical preventive care services available, such as screening tests for
different types of cancer or heart disease. Not everyone makes the same choices about
which tests to have, when to have a particular test or how often. By answering this
questionnaire, you will help MEPS learn about the different choices different people make
about preventive care.


REGION:
This Booklet
Should Be
Completed By  NAME:

RUID:

/

DOB:
MONTH

PID:

/
DAY

SEX:
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 inform ation 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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Your Health and Health Choices
START HERE:

1. Are you male or female?
Male

Please call Alex Scott, toll free at 1-800-945-6377 before completing.

Female
2. What is your age?
Under 18
18 to 34
35 to 49
50 or older
3. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
4. 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

“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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5. 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
6. 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
7. 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.
8. 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
9. 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

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10. 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
time
time

None of the
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?.....................................

11. 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

More than
half the days Several days

Not at all

a. Little interest or pleasure in doing things..........
b. Feeling down, depressed, or hopeless.............
12. During the past 30 days, how often have you experienced trouble getting to sleep or staying asleep?
Not at all
Once a month
Several times a month
Once a week
Several times a week
Almost every day

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Alcohol and Drug Use
13. Think about your drinking in the last 12 months. A drink means one beer, one small glass of wine
(5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.
How often do you have a drink containing alcohol?
Never
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily
14. How many drinks containing alcohol do you have on a typical day you are drinking? (A drink means
one beer, one small glass of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.)
1 drink
2 drinks
3 drinks
4 drinks
5-6 drinks
7-9 drinks
10 or more drinks
15. How often do you have 4 or more drinks on one occasion? (A drink means one beer, one small glass
of wine (5 oz.), or one mixed drink containing one shot (1.5 oz.) of spirits.)
Never
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily
16. 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.
Yes
No

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17. In the last 12 months, has a doctor, nurse, or other health care professional advised you to cut
back or stop drinking alcohol?
Yes
No
18. How many days in the past 12 months have you used drugs other than alcohol?
Days

19. How many days in the past 12 months have you used drugs more than you meant to?
Days

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Counseling and Treatment
20. People can get counseling, treatment or medicine for many different reasons, such as:
• For feeling depressed, anxious, or “stressed out”
• Personal problems (like when a loved one dies or when there are problems at work)
• Family problems (like marriage problems or when parents and children have trouble getting along)
• Needing help with drug or alcohol use
• For mental or emotional illness
In the last 12 months, did you get counseling, treatment or medicine for any of these reasons?
Yes
No

If No, go to 25

21. Using any number from 0 to 10, where 0 is the worst counseling or treatment possible and 10 is the
best counseling or treatment possible, what number would you use to rate all your counseling or
treatment in the last 12 months?
0 Worst counseling or treatment possible
1
2
3
4
5
6
7
8
9
10 Best counseling or treatment possible
22. In the last 12 months, how much were you helped by the counseling or treatment you got?
Not at all
A little
Somewhat
A lot

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23. How much of the counseling or treatment you got in the last 12 months was paid for by another
source besides you or your family?
All of it
Most of it
Some of it
None of it

24. In the last 12 months, how much of a problem, if any, was it to get any counseling or treatment you
thought you needed?
A big problem
A small problem
Not a problem

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Counseling Needs and Alternative Treatments
25. During the past 12 months, was there any time when you felt you needed counseling or treatment for
yourself but didn’t get it? Think about counseling or treatment for difficult feelings, personal or family
problems, drug or alcohol use, or any mental or emotional illness.
Yes
No

26. During the past 12 months, did you ever receive any treatment, counseling, or support including selfhelp for problems with your emotions, mental health, family or personal problems, or substance use
from any of the following other sources?
Yes

No

a. A spiritual or religious advisor...............................................
b. A school-based resource......................................................
c. An in-person peer support or self-help group.......................
d. An internet website or online support forum or group.............
e. A telephone hotline...............................................................
f. A smartphone app.................................................................
27. Have you ever worried about your family’s financial stability because of your mental health, its
treatment, or lasting effects of that treatment?
Yes
No

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Your Choices about Your Health
28. In the past 12 months, have you received counseling or information about birth control from a
doctor or other medical care provider?
Yes
No
29. When was the last time you visited a doctor or nurse for a check-up, follow-up care for an
ongoing problem, or a concern that you have about your health? Do not include times you
were hospitalized overnight or visits to the hospital emergency room.
Within the past 12 months
Within the past one to two years
Within the past two to five years
More than five years ago
Never
30. During the past 12 months, have you had either a flu shot (directly in the arm or into the skin)
or a flu vaccine that was sprayed in your nose?
Yes
No
31. In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
Yes
No
32. About how much do you weigh without shoes?
Weight (pounds)
33. About how tall are you without shoes?
Feet

Inches

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34. 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?
Yes
No
35. 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.
Yes
No
36. In the last 12 months, on average, would you say you smoked cigarettes or used tobacco
every day, some days, or not at all?
Every day
Some days
Not at all

If Not at all, go to 40

37. In the past 12 months, were you advised by a doctor, nurse, or other health care professional to
quit smoking or quit using tobacco?
Yes
No
38. 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.
Yes
No
39. 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.
Yes
No

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40. 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.
Yes
No
41. During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or
other health care professional?
Yes
No
42. Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or
other health care professional?
Yes
No
43. Have you had a hysterectomy or have you ever had cervical cancer?
Yes

If Yes, go to the next page

No


44. Within the past 5 years, have you had a Pap or human papillomavirus (HPV) test? A Pap or
HPV test is a routine test in which the doctor takes a cell sample from the cervix with a small
stick or brush, and sends it to the lab.
Yes
No
45. About how old were you the last time you had a Pap or HPV test?
Younger than 35
35 to 44 years old
45 to 54 years old
55 to 64 years old
65 to 74 years old
75 or older
I have never had a Pap or HPV test

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If you are 50 or older, please continue with the questions.
If you are under 50 years old, please go to the "Date Completed"
box on the last page.
46. 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.
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

47. 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.
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
48. Is there any medical reason why you cannot take aspirin, such as an allergy, another medication
you take, or other side effect?
Yes

If Yes, go to 50

No


49. Has a doctor, nurse, or other health care professional ever discussed with you the use of
aspirin to prevent heart attack or stroke?
Yes
No

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50. Have you ever been told by a doctor, nurse or other health care professional that you have
osteoporosis? Osteoporosis is when the bones become fragile and break easily.
Yes

If Yes, go to 52

No


51. There are several tests to measure bone density and detect osteoporosis at an early stage,
including a DEXA scan. Have you ever had your bone density measured?
Yes
No
52. Have you had both breasts removed or have you ever had breast cancer?
Yes

If Yes, go to 54

No


53. Within the past 2 years, have you had a mammogram? A mammogram is an x-ray taken
only of the breast by a machine that presses against the breast.
Yes
No
54. Have you had colon cancer or your entire colon removed?
Yes

If Yes, go to the “Date Completed” box on the next page

No


55. Within the past 10 years, have you had a colonoscopy? A colonoscopy test examines the
bowel by inserting a tube into the rectum. After a colonoscopy, you feel tired and usually
need someone to drive you home.
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
56. Within the past 5 years, have you had a sigmoidoscopy? A sigmoidoscopy test also
examines the bowel by inserting a tube into the rectum. You are awake during this test and
can drive yourself home.
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

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57. 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.
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

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 COMPLETING THE QUESTIONNAIRE!


Please place this survey in the envelope provided to you and give it to the
MEPS interviewer.



If the interviewer is no longer available, place the survey in the return
envelope provided to you by the interviewer. If the envelope is missing,
mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, Room GA51
Rockville, MD 20850

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