106b Attachment106b.REV_Male PSAQ with Mental Health Content

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 es timated 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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Your Health and Health Choices

1. Are you male or female?
Male
Female

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

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 X (5 for men age 65 and younger; 4 for men over age 65) 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
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. 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
29. 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
30. In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
Yes
No
31. About how much do you weigh without shoes?
Weight (pounds)
32. About how tall are you without shoes?
Feet

Inches

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33. 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

34. 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
35. 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 39

36. 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
37. 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

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38. 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
39. 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
40. During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other
health care professional?
Yes
No
41. Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other
health care professional?
Yes
No

If you are 50 or older, please continue with the questions.
If you are under 50 years old, please turn to the back cover.

42. 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

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43. 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
44. 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 46

No


45. 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
46. Have you had colon cancer or your entire colon removed?
Yes

If Yes, go to 50

No


47. 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

48. 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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49. 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
50. Have you had prostate cancer?
Yes

If Yes, go to the "Date Completed" box on the back cover

No
51. About how old were you the last time you had a PSA test? A "P-S-A" is a blood test to detect prostate
cancer. It is also called a prostate specific antigen test.
Never had a PSA test
Under age 50
Between 51 and 64
Between 65 and 74
75 or older

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`
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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