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pdfAttachment C. HOS Field Test Item Differences by Questionnaire Version
Field Test Questionnaire Version A
Field Test Questionnaire Version B
2. Does your health now limit you in these
activities? If so, how much?
2. 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
a. Moderate activities, such as moving a
table, pushing a vacuum cleaner, or walking
at a brisk pace
1
Yes, limited a lot
1
Yes, limited a lot
2
Yes, limited a little
2
Yes, limited a little
3
No, not limited at all
3
No, not limited at all
6. How much of the time during the past 4
weeks:
a. Have you felt calm and peaceful?
6. How much of the time during the past 4
weeks:
a. Have you felt calm and peaceful?
1
All of the time
1
All of the time
2
Most of the time
2
Most of the time
3
A good bit of the time
4
Some of the time
4
Some of the time
5
A little of the time
5
A little of the time
6
None of the time
6
None of the time
b. Did you have a lot of energy?
b. Did you have a lot of energy?
1
All of the time
1
All of the time
2
Most of the time
2
Most of the time
3
A good bit of the time
4
Some of the time
4
Some of the time
5
A little of the time
5
A little of the time
6
None of the time
6
None of the time
c. Have you felt downhearted and sad?
1
2
All of the time
Most of the time
c. Have you felt downhearted and sad?
1
All of the time
2
Most of the time
3
A good bit of the time
4
Some of the time
4
Some of the time
5
A little of the time
5
A little of the time
None of the time
6
None of the time
6
1
Field Test Questionnaire Version A
Field Test Questionnaire Version B
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?
8. Because of a health or physical problem, do
you have any difficulty doing the following
activities without help from another
person?
12. Does your health now limit you in doing
moderate activities, such as moving a table,
pushing a vacuum cleaner, bowling, or
playing golf?
12. Does your health now limit you in doing
moderate activities, such as moving a table,
pushing a vacuum cleaner, or walking at a
brisk pace?
5
Not at all
5
Not at all
4
Very little
4
Very little
3
Somewhat
3
Somewhat
2
Quite a lot
2
Quite a lot
1
Cannot do
1
Cannot do
42. In the past 12 months, how often did you have
reliable transportation for medical
appointments?
42. In the past 12 months, how often did you
struggle with having reliable transportation
for medical appointments?
1
Never
1
Never
2
Rarely
2
Rarely
3
Sometimes
3
Sometimes
4
Often
4
Often
5
Always
5
Always
46. In the past 12 months, how often did you have
enough food to eat?
46. In the past 12 months, how often did you
struggle with having enough food to eat?
1
Never
1
Never
2
Rarely
2
Rarely
3
Sometimes
3
Sometimes
4
Often
4
Often
5
Always
5
Always
2
Field Test Questionnaire Version A
50. In the past 12 months, how often did you have
a steady place to live?
Field Test Questionnaire Version B
50. In the past 12 months, how often did you
struggle with having a steady place to live?
1
Never
1
Never
2
Rarely
2
Rarely
3
Sometimes
3
Sometimes
4
Often
4
Often
5
Always
5
Always
3
| File Type | application/pdf |
| File Title | Attachment C. HOS Field Test Item Differences by Questionnaire Version |
| Author | Centers for Medicare & Medicaid Services (CMS) |
| File Modified | 2023-06-09 |
| File Created | 2023-05-31 |