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

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Your Health And Health Opinions

(Core + PSAQ_M)



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MEPS Preventive SAQ – Male 1-2


  1. Are you male or female?

Male

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



  1. What is your age?

Under 18

18 to 34

35 to 49

50 or older



VR12: 1-7 – Medicare HOS survey items 1-7



  1. In general, would you say your health is:

Excellent

Very Good

Good

Fair

Poor





  1. 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?

    1. 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



    1. Climbing several flights of stairs

Yes, limited a lot

Yes, limited a little

No, not limited at all



  1. 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?

  1. 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


  1. 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


  1. 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)?

  1. 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


  1. 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



  1. 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.

  1. How much of the time during the past 4 weeks:

    1. 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


    1. 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



    1. 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





  1. 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

  1. 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


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  1. nervous?

  1. hopeless?

  1. restless of fidgety?

  1. so sad that nothing could cheer you up?

  1. that everything was an effort?

  1. worthless?








  1. 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


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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

  1. 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    



  1. 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





  1. In the past 12 months, has a doctor, nurse, or other health care professional weighed you?

Yes

No





  1. About how much do you weigh without shoes?




Weight (pounds)







  1. About how tall are you without shoes?



  2. Feet



    Inches




    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





  1. 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





  1. 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





  1. 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



  1. 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







  1. 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





  1. 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





  1. 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





  1. 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





  1. 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









  1. During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or other health care professional?

Yes

No



  1. 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.



  1. 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





  1. 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



  1. 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

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No





  1. 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

  1. Have you had colon cancer or your entire colon removed?

Yes If Yes, go to 37

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No



  1. 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





  1. 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



  1. 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



  1. Have you had prostate cancer?

Yes Please turn to the back cover

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No





  1. 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





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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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