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pdfMedicare Health Outcomes Survey (HOS)
Field Test Questionnaire Version A
(English)
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 because your answers are very important to us.
If you need help to complete this survey, a family member or friend can help 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
Male
2
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
Yes Go to Question 29
2
No Go to Question 32
If you are filling out this survey for someone else, please answer each question the way you
think the person you are helping would answer about themselves.
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. This applies to both
mandatory and voluntary collections of information. The OMB control number for this information
collection is [OMB Control Number] [expiration date]. 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.
© [DATE] 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.
Medicare Health Outcomes Survey
1. In general, would you say your health is:
1
Excellent
2
Very good
3
Good
4
Fair
5
Poor
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
Yes, limited a lot
2
Yes, limited a little
3
No, not limited at all
b. Climbing several flights of stairs
b. Were limited in the kind of work or other
activities as a result of your physical
health?
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
Yes, all 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)?
a. Accomplished less than you would like
as a result of any emotional problems
1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
1
Yes, limited a lot
4
Yes, most of the time
2
Yes, limited a little
5
Yes, all of the time
3
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
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
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
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
4
Yes, most of the time
5
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)?
c. Have you felt downhearted and sad?
1
All of the time
2
Most of the time
1
Not at all
3
A good bit of the time
2
A little bit
4
Some of the time
3
Moderately
5
A little of the time
4
Quite a bit
6
None of the time
5
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
All of the time
2
Most of the time
3
A good bit of the time
4
Some of the time
5
A little of the time
6
None of the time
b. Did you have a lot of energy?
1
All of the time
2
Most of the time
3
A good bit of the time
4
Some of the time
5
A little of the time
6
None of the time
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
All of the time
2
Most of the time
3
Some of the time
4
A little of the time
5
None of the time
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.
8. Because of a health or physical problem,
do you have any difficulty doing the
following activities without special
equipment or help from another
person?
a. Bathing
9. Are you able to walk briskly for 20 minutes
without stopping to rest?
5
Without any difficulty
4
With a little difficulty
3
With some difficulty
2
With much difficulty
1
Unable to do
10. Are you able to climb up 5 flights of stairs?
1
No, I do not have difficulty
2
Yes, I have difficulty
5
Without any difficulty
3
I am unable to do this activity
4
With a little difficulty
3
With some difficulty
2
With much difficulty
1
Unable to do
b. Dressing
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
c. Eating
11. Does your health now limit you in bending,
kneeling, or stooping?
5
Not at all
1
No, I do not have difficulty
4
Very little
2
Yes, I have difficulty
3
Somewhat
3
I am unable to do this activity
2
Quite a lot
1
Cannot do
d. Getting in or out of chairs
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
e. Walking
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
f. Using the toilet
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
12. Does your health now limit you in doing
moderate activities, such as moving a
table, pushing a vacuum cleaner, bowling,
or playing golf?
5
Not at all
4
Very little
3
Somewhat
2
Quite a lot
1
Cannot do
13. Does your health now limit you in doing
heavy work around the house like moving
heavy furniture?
18. In the past month, how often did memory
problems interfere with your daily
activities?
5
Not at all
1
Every day (7 days a week)
4
Very little
2
Most days (5-6 days a week)
3
Somewhat
3
Some days (2-4 days a week)
2
Quite a lot
4
Rarely (once a week or less)
1
Cannot do
5
Never
Now we are going to ask some questions
about specific medical conditions.
14. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
1
Yes
2
No
15. Are you deaf or do you have serious
difficulty hearing, even with a hearing aid?
1
Yes
2
No
16. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?
1
Yes
2
No
17. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
1
Yes
2
No
Has a doctor ever told you that you had:
19. Hypertension or high blood pressure
1
Yes
2
No
20. Angina pectoris or coronary artery disease
1
Yes
2
No
21. Emphysema, or asthma, or COPD
(chronic obstructive pulmonary disease)
1
Yes
2
No
22. Diabetes, high blood sugar, or sugar in
the urine
1
Yes
2
No
23. Depression
1
Yes
2
No
24. Any cancer (other than skin cancer)
1
Yes
2
No
25. In the past 7 days, how much did pain
interfere with your day to day activities?
1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
5
Very much
26. In the past 7 days, how often did pain
keep you from socializing with others?
d. Feeling down, depressed, or hopeless
1
Not at all
2
Several days
3
More than half the days
4
Nearly every day
28. Many people experience leakage of urine,
also called urinary incontinence. In the
past six months, have you experienced
leaking of urine?
1
Never
1
Yes Go to Question 29
2
Rarely
2
No Go to Question 32
3
Sometimes
4
Often
5
Always
27. Over the last 2 weeks, how often have
you been bothered by any of the following
problems?
a. Feeling nervous, anxious or on edge
29. During the past six months, how much
did leaking of urine make you change your
daily activities or interfere with your sleep?
1
A lot
2
Somewhat
3
Not at all
30. Have you ever talked with a doctor, nurse,
or other health care provider about leaking
of urine?
1
Not at all
2
Several days
3
More than half the days
1
Yes
4
Nearly every day
2
No
b. Not being able to stop or control
worrying
1
Not at all
2
Several days
3
More than half the days
4
Nearly every day
c. Little interest or pleasure in doing
things
1
Not at all
2
Several days
3
More than half the days
4
Nearly every day
31. 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
Yes
2
No
32. 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
Yes Go to Question 33
2
No Go to Question 33
3
I had no visits in the past 12
months Go to Question 34
33. 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.
37. 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
Yes
2
No
3
I had no visits in the past 12
months
38. 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.)
1
Less than 5 hours
1
Yes
2
5 – 6 hours
2
No
3
7 – 8 hours
4
9 or more hours
34. 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?
39. During the past month, how would you
rate your overall sleep quality?
1
Very Good
1
Yes
2
Fairly Good
2
No
3
Fairly Bad
I had no visits in the past 12
months
4
Very Bad
3
40. How much do you weigh in pounds (lbs.)?
35. Did you fall in the past 12 months?
1
Yes
2
No
36. In the past 12 months, have you had a
problem with balance or walking?
1
Yes
2
No
lbs.
41. 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
Your access to transportation, food, and
housing can impact your health.
The following questions are about whether
you have reliable transportation for
medical appointments. This can mean
access to a vehicle, public transportation,
someone to drive you, or another way to get
to appointments.
42. In the past 12 months, how often did you
have reliable transportation for medical
appointments?
1
Never
2
Rarely
3
Sometimes
4
Often
5
Always
43. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office ask you if you had reliable
transportation for medical appointments?
1
Yes
2
No
44. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office help you get reliable transportation
for medical appointments? Please select
all that apply.
1
2
3
They provided transportation or a
ride service
They gave me information or
referred me to someone that could
help
The following questions are about whether
you have enough food to eat. This can
mean not eating as much as you should
because there is not enough money for food.
46. In the past 12 months, how often did you
have enough food to eat?
1
Never
2
Rarely
3
Sometimes
4
Often
5
Always
47. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office ask you if you had enough food to
eat?
1
Yes
2
No
48. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office help you get enough food to eat?
Please select all that apply.
1
2
3
4
I did not get help
45. Do you currently have reliable
transportation for medical appointments?
1
Yes
2
No
5
I received a healthy food benefit
card from my Medicare Advantage
plan
They connected me with a food
pantry
They helped me sign up for
assistance like Meals on Wheels or
the Supplemental Nutrition
Assistance Program (SNAP)
They gave me information or
referred me to someone that could
help
I did not get help
49. Do you have enough food to eat this
month?
1
Yes
2
No
The following questions are about whether
you have a steady place to live. This can
mean having a consistent place to stay, and
not having to stay with others temporarily,
stay in a hotel, or stay in a shelter.
54. Are you male or female?
50. In the past 12 months, how often did you
have a steady place to live?
55. Are you of Hispanic, Latino/a or Spanish
origin? (One or more categories may be
selected)
1
Never
2
Rarely
3
Sometimes
4
Often
5
Always
51. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office ask you if you had a steady place to
live?
1
Yes
2
No
52. In the past 12 months, did someone from
your Medicare Advantage plan or doctor’s
office help you get a steady place to live?
Please select all that apply.
1
2
3
1
Male
2
Female
1
2
No, not of Hispanic, Latino/a, or
Spanish origin
Yes, Mexican, Mexican American,
Chicano/a
3
Yes, Puerto Rican
4
Yes, Cuban
5
Yes, another Hispanic, Latino/a, or
Spanish origin
56. What is your race? (One or more
categories may be selected)
03
American Indian or Alaska Native
16
Asian – If YES:
They helped me find housing or
shelter
They gave me information or
referred me to someone that could
help
I did not get help
04
Asian Indian
05
Chinese
06
Filipino
07
Japanese
08
Korean
09
Vietnamese
10
Other Asian
Black or African American
02
53. Do you currently have a steady place to
live?
Native Hawaiian or Other Pacific
Islander – If YES:
15
1
Yes
11
Native Hawaiian
2
No
12
Guamanian or Chamorro
13
Samoan
14
Other Pacific Islander
NOTE: If you need assistance, please
contact your Medicare Advantage plan or
doctor’s office to ask about your options.
01
White
57. What language do you mainly speak at
home?
1
English
2
Spanish
3
Chinese
4
Russian
7
Some other language (please
specify)
58. What is your current marital status?
1
Married
2
Divorced
3
Separated
4
Widowed
5
Never married
59. What is the highest grade or level of
school that you have completed?
1
2
8th grade or less
Some high school, but did not
graduate
3
High school graduate or GED
4
Some college or 2-year degree
5
4-year college graduate
6
More than a 4-year college degree
YOU HAVE COMPLETED THE SURVEY.
PLEASE RETURN IT IN THE ENCLOSED
PREPAID ENVELOPE. THANK YOU.
Centers for Medicare & Medicaid Services
c/o Survey Processing
[Insert Survey Vendor Return Address Here]
| File Type | application/pdf |
| File Title | Attachment A. HOS Field Test Questionnaire Version A |
| Author | Centers for Medicare & Medicaid Services (CMS) |
| File Modified | 2023-06-09 |
| File Created | 2023-06-06 |