Form CMS-10203 Medicare Health Outcomes Survey (HOS 3.0)

Attachment B.
Medicare Health Outcomes Survey
Questionnaire (English)
HOS 3.1

Medicare Health Outcomes Survey Instructions
This survey asks about you and your health. Answer each question, thinking about yourself.
Please take the time to complete this survey. Your answers are very important to us. If you are
unable to complete this survey, a family member or “proxy” can fill out the survey about you.
Please return the survey with your answers in the enclosed postage-paid envelope.
 Answer the questions by putting an ‘X’ in the box next to the appropriate answer like the example
below.
Are you male or female?
1
2

Male
Female

 Be sure to read all the answer choices given before marking a box with an ‘X’.
 You are sometimes told to skip over some questions in this survey. When this happens you will see
a note that tells you what question to answer next, like this:
1
2

Yes Go to Question 35
No Go to Question 36

All information that would permit identification of any person who completes this survey is
protected by the Privacy Act and the Health Insurance Portability and Accountability Act
(HIPAA). This information will be used only for purposes permitted by law and will not be
disclosed or released for any other reason. If you have any questions or want to know more
about the study, please call [survey vendor name] at [phone number].
“According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information that does not display a valid OMB control number. The valid OMB
control number for this information collection is 0938-0701. The time required to complete this
information collection is estimated to average 20 minutes including the time to review
instructions, search existing data resources, gather the data needed, and complete and review
the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, C1-25-05, Baltimore, Maryland 21244-1850.”
OMB 0938-0701 Version 02-1 (Expires: XX/XX/XXXX)
© 2021 by the National Committee for Quality Assurance (NCQA). This survey instrument may not be reproduced or
transmitted in any form, electronic or mechanical, without the express written permission of NCQA. All rights reserved.
Items 1–9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.

Medicare Health Outcomes Survey
1. In general, would you say your health is:
1
2
3
4
5

Excellent

b. Were limited in the kind of work or other
activities as a result of your physical
health?

Very good
1

Good
2

Fair
Poor

3
4

5

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
1
2

3

Yes, limited a lot

1

No, not limited at all

2

b. Climbing several flights of stairs
4

2

3

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?
1
2

3
4

5

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

Yes, most of the time
Yes, all of the time

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
1
2

3
4

5

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
1
2

3
4

5

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Yes, some of the time

a. Accomplished less than you would like
as a result of any emotional problems

Yes, limited a little

Yes, limited a lot

Yes, a little of the time

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)?

3

1

No, none of the time

A little bit
Moderately
Quite a bit
Extremely

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?
1
2

3
4

5
6

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.)?
1
2

All of the time

3

Most of the time

4

A good bit of the time

5

2

3
4

5
6

A little of the time
None of the time

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?
1
2

3
4

5
6

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

Some of the time
Now, we’d like to ask you some questions
about how your health may have changed.
8. Compared to one year ago, how would
you rate your physical health in general
now?

b. Did you have a lot of energy?
1

All of the time

1
2

3
4

5

1

Most of the time

2

A good bit of the time

3

Some of the time

4

A little of the time

5

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Slightly better
About the same
Slightly worse
Much worse

9. Compared to one year ago, how would
you rate your emotional problems (such
as feeling anxious, depressed, or irritable)
in general now?

All of the time

None of the time

Much better

Much better
Slightly better
About the same
Slightly worse
Much worse

Earlier in the survey you were asked to
indicate whether you have any limitations in
your activities. We are now going to ask a few
additional questions in this area.
10. Because of a health or physical problem,
do you have any difficulty doing the
following activities without special
equipment or help from another
person?

11. Because of a health or physical problem,
do you have any difficulty doing the
following activities?
a. Preparing meals
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I don’t do this activity

a. Bathing
1
2

3

No, I do not have difficulty

b. Managing money

Yes, I have difficulty

1

I am unable to do this activity

2

3

No, I do not have difficulty
Yes, I have difficulty
I don’t do this activity

b. Dressing
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I am unable to do this activity

c. Eating
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I am unable to do this activity

d. Getting in or out of chairs
1
2

3

No, I do not have difficulty
Yes, I have difficulty

c. Taking medication as prescribed
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I don’t do this activity

These next questions ask about your physical
and mental health during the past 30 days.
12. Now, thinking about your physical health,
which includes physical illness and injury,
for how many days during the past 30
days was your physical health not
good?
Please enter a number between "0" and
"30" days. If no days, please enter “0”
days. Your best estimate would be fine.

I am unable to do this activity
days

e. Walking
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I am unable to do this activity

f. Using the toilet
1
2

3

No, I do not have difficulty
Yes, I have difficulty
I am unable to do this activity

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13. Now, thinking about your mental health,
which includes stress, depression, and
problems with emotions, for how many
days during the past 30 days was your
mental health not good?
Please enter a number between "0" and
"30" days. If no days, please enter “0”
days. Your best estimate would be fine.
days

14. During the past 30 days, for about how
many days did poor physical or mental
health keep you from doing your usual
activities, such as self-care, work, or
recreation?
Please enter a number between "0" and
"30" days. If no days, please enter “0”
days. Your best estimate would be fine.

19. In the past month, how often did memory
problems interfere with your daily
activities?
1
2

3
4

days
5

Now we are going to ask some questions
about specific medical conditions.
15. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
1
2

Yes
No

16. Are you deaf or do you have serious
difficulty hearing, even with a hearing aid?
1
2

Yes
No

17. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?
1
2

1
2

Some days (2-4 days a week)
Rarely (once a week or less)
Never

20. Hypertension or high blood pressure
1
2

Yes
No

21. Angina pectoris or coronary artery
disease
1
2

Yes
No

22. Congestive heart failure
1
2

Yes
No

23. A myocardial infarction or heart attack
1
2

18. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?

Most days (5-6 days a week)

Has a doctor ever told you that you had:

Yes
No

Every day (7 days a week)

Yes
No

24. Other heart conditions, such as problems
with heart valves or the rhythm of your
heartbeat

Yes

1

No

2

Yes
No

25. A stroke
1
2

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Yes
No

Has a doctor ever told you that you had:
26. Emphysema, or asthma, or COPD
(chronic obstructive pulmonary disease)
Yes

1

No

2

27. Crohn’s disease, ulcerative colitis, or
inflammatory bowel disease
Yes

1

No

2

28. Osteoporosis, sometimes called thin or
brittle bones
Yes

1

No

2

29. Diabetes, high blood sugar, or sugar in
the urine

c. Breast cancer
1
2

1
2

1
2

No

Yes
No

33. In the past 7 days, how much did pain
interfere with your day to day activities?
1

3

No
4

30. Depression

Yes

e. Other cancer (other than skin cancer)

Yes

2

No

d. Prostate cancer

2

1

Yes

5

Not at all
A little bit
Somewhat
Quite a bit
Very much

Yes

1

No

2

34. In the past 7 days, how often did pain
keep you from socializing with others?

31. Any cancer (other than skin cancer)
1
2

Yes Go to Question 32

1

No Go to Question 33

2

32. Are you currently under treatment for:
a. Colon or rectal cancer
1
2

Yes
No

b. Lung cancer
1
2

Yes
No

OMB 0938-0701 (Expires XX/XX/XX)

3
4

5

Never
Rarely
Sometimes
Often
Always

35. In the past 7 days, how would you rate
your pain on average?
No pain
00
01
02

03
04

05
06
07

08
09

10

1
2
3
4
5
6
7
8

37. In general, compared to other people your
age, would you say that your health is:
1
2

3
4

5

1
2

36. Over the past 2 weeks, how often have
you been bothered by any of the following
problems?
a. Little interest or pleasure in doing
things

2

3
4

Not at all
2

Several days
3

2

3
4

Fair
Poor

Yes Go to Question 39
No Go to Question 42

A lot
Somewhat
Not at all

More than half the days
Nearly every day

b. Feeling down, depressed, or hopeless
1

Good

39. During the past six months, how much
did leaking of urine make you change your
daily activities or interfere with your sleep?
1

1

Very good

38. Many people experience leakage of urine,
also called urinary incontinence. In the
past six months, have you experienced
leaking of urine?

9
10 Worst imaginable pain

Excellent

40. Have you ever talked with a doctor,
nurse, or other health care provider about
leaking of urine?

Not at all

1

Several days

2

Yes
No

More than half the days
Nearly every day

41. There are many ways to control or
manage the leaking of urine, including
bladder training exercises, medication,
and surgery. Have you ever talked with a
doctor, nurse, or other health care
provider about any of these approaches?
1
2

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Yes
No

42. In the past 12 months, did you talk with a
doctor or other health provider about your
level of exercise or physical activity? For
example, a doctor or other health provider
may ask if you exercise regularly or take
part in physical exercise.
1
2
3

Yes Go to Question 43
No Go to Question 43
I had no visits in the past 12

47. Has your doctor or other health provider
done anything to help prevent falls or treat
problems with balance or walking? Some
things they might do include:
• Suggest that you use a cane or
walker.
• Suggest that you do an exercise or
physical therapy program.
• Suggest a vision or hearing test.
1

months Go to Question 44
2

43. In the past 12 months, did a doctor or
other health provider advise you to start,
increase or maintain your level of exercise
or physical activity? For example, in order
to improve your health, your doctor or
other health provider may advise you to
start taking the stairs, increase walking
from 10 to 20 minutes every day or to
maintain your current exercise program.
1
2

3

1
2

No

3

2
3

No

Less than 5 hours
5 – 6 hours
7 – 8 hours
9 or more hours

49. During the past month, how would you
rate your overall sleep quality?
Very Good
1
2

Yes

I had no visits in the past 12

48. During the past month, on average, how
many hours of actual sleep did you get at
night? (This may be different from the
number of hours you spent in bed.)

4

1

No
months

Yes

44. A fall is when your body goes to the
ground without being pushed. In the past
12 months, did you talk with your doctor
or other health provider about falling or
problems with balance or walking?

Yes

3
4

Fairly Good
Fairly Bad
Very Bad

I had no visits in the past 12
months

50. How much do you weigh in pounds (lbs.)?
lbs.

45. Did you fall in the past 12 months?
1
2

Yes
No

46. In the past 12 months, have you had a
problem with balance or walking?
1
2

Yes
No

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51. How tall are you without shoes on, in feet
and inches? Please fill in both feet and
inches, for example: 5 feet 00 inches, or
5 feet 04 inches (if 1/2 inch, please round
up).
feet

inches

52. Are you male or female?
1
2

Male
Female

55. What language do you mainly speak at
home?
1
2

53. Are you Hispanic, Latino/a or Spanish
origin? (One or more categories may be
selected)
No, not of Hispanic, Latino/a or

3
4
7

3
4

5

Spanish origin
Yes, Mexican, Mexican American,
Chicano/a
Yes, Puerto Rican

1

Yes, another Hispanic, Latino/a or

2

54. What is your race? (One or more
categories may be selected)
01
02

03
04

05
06
07

08
09

10
11

12
13

14

Chinese
Russian
Some other language (please

56. What is your current marital status?

Yes, Cuban
Spanish origin

Spanish

specify)

1

2

English

3
4

5

Married
Divorced
Separated
Widowed
Never married

White
Black or African American

57. What is the highest grade or level of
school that you have completed?

American Indian or Alaska Native
1

Asian Indian
2

Chinese
Filipino

3

Japanese

4

Korean

8th grade or less
Some high school, but did not
graduate
High school graduate or GED
Some college or 2-year degree

5

4-year college graduate

6

More than a 4-year college degree

Vietnamese
Other Asian
Native Hawaiian

58. Do you live alone or with others? (One or
more categories may be selected)

Guamanian or Chamorro

1

Samoan

2

Other Pacific Islander

3
4
5

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Alone
With spouse/significant other
With children/other relatives
With non-relatives
With paid caregiver

59. Where do you live?
House, apartment, condominium or

1

mobile home Go to Question 60
Assisted living or board and care

2

home Go to Question 60
Nursing home Go to Question 61

3

62. Did someone help you complete this
survey? If so, please fill in that person’s
name.
DO NOT enter the name of the person to
whom this survey was addressed.
Please print clearly.

Other Go to Question 61

4

First Name: _______________________

60. Is the house or apartment you currently
live in:
1
2

3
4

5

Owned or being bought by you
Owned or being bought by
someone in your family other than
you
Rented for money
Not owned and one in which you
live without payment of rent
None of the above

61. Who completed this survey form?
1

2

3

4

Last Name: _______________________

Person to whom survey was
addressed  End of Survey
Family member or relative of
person to whom the survey was
addressed
Friend of person to whom the
survey was addressed
Professional caregiver of person to
whom the survey was addressed

OMB 0938-0701 (Expires XX/XX/XX)

YOU HAVE COMPLETED THE SURVEY.
THANK YOU.
Please use the enclosed prepaid envelope to
mail your completed survey to:
[Insert Survey Vendor
Contact Information Here]