Form Attachment 19 Attachment 19 Attachment 19 – HC Adult SAQ – Male
Medical Expenditure Panel Survey (MEPS) COVID-19 Changes
Attachment 19 HC Adult SAQ Male
Attachment 19 – HC Adult SAQ – Male
OMB: 0935-0118
Your Health And Health Opinions
(Core + PSAQ_M)
MEPS Preventive SAQ – Male 1-2
Are you male or female?
Male
Female Please call Alex Scott, toll free at 1-800-945-6377 before completing
What is your age?
Under 18
18 to 34
35 to 49
50 or older
VR12: 1-7 – Medicare HOS survey items 1-7
In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
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?
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
Climbing several flights of stairs
Yes, limited a lot
Yes, limited a little
No, not limited at all
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?
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
Were limited in the kind of work or other activities as 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
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)?
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
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
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
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.
How much of the time during the past 4 weeks:
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
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
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
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
MEPS SAQ 2013: 35-42
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 time |
A little of the time |
None of the time |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
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 |
|
|
|
|
Your Choices about Your Health |
|
If you are 35 or older, please continue with the questions. If you are under 35 years old, please turn to the back cover. |
MEPS Preventive SAQ – Male
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
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
In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
Yes
No
About how much do you weigh without shoes?
|
|
|
Weight (pounds) |
About how tall are you without shoes?
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?
Feet
Inches
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?
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.)
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?
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.
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?
Every day
Some days
Not at all If Not at all, go to 26
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
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
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
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
During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional?
Yes
No
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. |
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
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
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 33
No
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
Have you had colon cancer or your entire colon removed?
Yes If Yes, go to 37
No
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
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
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
Have you had prostate cancer?
Yes Please turn to the back cover
No
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
|
|
/ |
|
|
/ |
|
|
|
|
|
Date completed:
Month Day Year
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
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Andrew Caporaso |
| File Modified | 0000-00-00 |
| File Created | 2022-10-06 |
© 2024 OMB.report | Privacy Policy