MEC Exam Hand Cards

Attachment 6e

2025-2026 Home Interview Hand Cards

Attachment 6e: 2025-2026 Home Interview Hand Cards

CARD HEQ1

Prescribed Medicines for Hepatitis B

Adefovir

Alinia

Baraclude

Descovy

Entecavir

Epivir

Epivir-HBV

Hepsera

Heptodin

Interferon/Peginterferon

Interferon Alpha

Intron A

Lamivudine

Levovir (cledvudine)

Nitazoxanide

Pegasys

Pegylated interferon

Roferon-A

Sebivo

Telbivudine

Tenofovir

Tyzeka

Vemlidy

Viread

Zeffix

CARD HEQ2

Prescribed Medicines for Hepatitis C

Alinia

Boceprevir

Copegus

Daklinza (Daclatasvir)

Epclusa

Harvoni

Incivek

Infergen

Interferon/Peginterferon

Intron A

Ledipasvir

Mayvret

Moderiba

Nitazoxanide

Olysio (simeprevir)

Pegasys

Peg-intron

Rebetol

Rebetron

Ribapak

Ribasphere

Ribatab

Ribavirin

Roferon-A

Sovaldi (sofosbuvir)

Technivie

Telaprevir

Victrelis

Viekira Pak

Viekira XR

Vosevi

Zepatier

CARD OSQ2

Prescribed Medicines for Osteoporosis

Fosamax, Alendronate

Boniva, Ibandronate

Actonel, Atelvia, Risedronate

Reclast, Zoledronic acid

Fortical, Miacalcin, Calcitonin

Evista, Raloxifene

Forteo, Teriparatide

Duavee, Bazedoxifene

Prolia, Denosumab

CARD AGQ2

Peanuts

Almonds

Walnuts

Cashews

Cow’s Milk

Eggs

Shrimp or Shellfish

Other Fish

Wheat

Soy

Sesame

Other Foods

CARD VIQ1

No difficulty

A little difficulty

Moderate difficulty

Extreme difficulty

Unable to do because of eyesight

Does not do this for other reasons

CARD VIQ2

No difficulty

A little difficulty

Moderate difficulty

Extreme difficulty

Unable to do because of eyesight

Does not do this for other reasons

Never drove

CARD AUQ1

GENETIC/HEREDITARY CAUSES

EAR INFECTIONS (INCLUDING FLUID IN EARS)

EAR DISEASES (OTOSCLEROSIS, MENIERES, TUMOR)

ILLNESS/INFECTIONS (MEASLES, MENINGITIS, MUMPS)

DRUGS/MEDICATIONS

HEAD OR NECK INJURY/TRAUMA

LOUD BRIEF EXPLOSIVE NOISE/SOUNDS

NOISE EXPOSURE, LONG-TERM (MACHINERY, ETC.)

AGING, GETTING OLDER

OTHER CAUSES

CARD AUQ2

Always

Usually

About half the time

Seldom

Never

CARD AUQ3

Speech-language

Reading

Hearing or listening skills

Intellectual disability

Movement or mobility difficulties

Other developmental or disability problems

CARD AUQ4

AUTISM, AUTISM SPECTRUM DISORDER, ASPERGER'S DISORDER OR PERVASIVE DEVELOPMENTAL DISORDER

ATTENTION DEFICIT/HYPERACTIVITY DISORDER (ADHD) OR ATTENTION-DEFICIT DISORDER (ADD)

ANXIETY

DEPRESSION

OBSESSIVE-COMPULSIVE DISORDER

INTELLECTUAL DISABLITY (INCLUDING DOWN SYNDROME, FETAL ALCOHOL SYNDROME, FRAGILE X SYNDROME)

NONE OF THESE

CARD AUQ6

LESS THAN 3 MONTHS

3 TO 11 MONTHS

1 TO 2 YEARS

3 TO 4 YEARS

5 TO 9 YEARS

10 TO 14 YEARS

15 OR MORE YEARS

CARD OHQ1

Went in on own for check-up, examination or cleaning

Was called in by the dentist for check-up, examination or cleaning

Something was wrong, bothering or hurting

Went for treatment of a condition that dentist discovered at earlier check-up or examination

Other

CARD OHQ2

Could not afford the cost

Did not want to spend the money

Insurance did not cover recommended procedures

Dental office is too far away

Dental office is not open at convenient times

Afraid or do not like dentists

Unable to take time off from work

Too busy

Did not think anything serious was wrong/expected dental problems to go away

Other

CARD OHQ3

CARD OHQ4

Very often

Fairly often

Occasionally

Hardly ever

Never

CARD OHQ5

CARD OHQ6

Do not have access to tap water in my home

Do not like the taste of tap water

Do not think my tap water is clean to drink

Do not think my tap water is safe to drink

Other

CARD FNQ1

No difficulty

Some difficulty

A lot of difficulty

Cannot do at all

CARD FNQ2

Some difficulty

A lot of difficulty

Cannot do at all

CARD DBQ1

Never

1-3 Times in the last 7 days

4-6 Times in the last 7 days

1 Time per day

2 Or more times per day

CARD DBQ2

Examples of grain snacks for babies:

CARD DBQ3

Examples of infant cereal:

CARD DBQ1

Never

1-3 Times in the last 7 days

4-6 Times in the last 7 days

1 Time per day

2 Or more times per day

CARD DBQ4

Never

Rarely – less than once a week

Sometimes – once a week or more, but less than once a day

Often – once a day or more

CARD SMQ1

CARD COQ1

Change or loss of smell or taste

Changes in menstrual cycles

Chest pain

Cough

Depression and/or anxiety

Diarrhea

Difficulty breathing or shortness of breath

Difficulty thinking or concentrating (sometimes referred to as “brain fog”)

Difficulty with memory

Dizziness when you stand up (lightheadedness)

Fast-beating or pounding heart (also known as heart palpitations)

Fever

Headache

Joint or muscle pain

Pins-and-needles feelings

Rash

Sleep problems

Stomach pain

Symptoms that get worse after physical or mental effort (also known as “post-exertional malaise”)

Tiredness or fatigue that interferes with daily life

Other symptom

CARD DMQ1

Never attended/kindergarten only

Grade 1-11

12th grade, no diploma

High school graduate

GED or equivalent

Some college, no degree

Associate’s degree (Example: AA, AS)

Bachelor’s degree (Example: BA, AB, BS, BBA)

Master’s degree (Example: MA, MS, MEng, MEd, MBA)

Professional school degree (Example: MD, DDS, DVM, JD)

Doctoral degree (Example: PhD, EdD)

CARD DMQ2

MEXICAN

CARIBBEAN:

PUERTO RICAN

CUBAN

DOMINICAN

CENTRAL AMERICAN:

COSTA RICAN

GUATEMALAN

HONDURAN

NICARAGUAN

PANAMANIAN

SALVADORAN

OTHER CENTRAL AMERICAN

SOUTH AMERICAN:

ARGENTINEAN

BOLIVIAN

CHILEAN

COLOMBIAN

ECUADORIAN

PARAGUAYAN

PERUVIAN

URUGUAYAN

VENEZUELAN

OTHER SOUTH AMERICAN

OTHER HISPANIC OR LATINO:

FILIPINO

SPANIARD

SPANISH

SPANISH AMERICAN

HISPANO/HISPANA

HISPANIC/LATINO

OTHER HISPANIC/LATINO (SPECIFY)

CHICANA/CHICANO

REFUSED

DON’T KNOW

CARD ACQ2

English

SPANISH

Chinese

Japanese

Korean

Vietnamese

Other (SPECIFY)

CARD HIQ1

Private Health Insurance

Medicare

Medi-Gap

Medicaid

Children’s Health Insurance Program (CHIP)

Military Related Healthcare: Tricare (CHAMPUS)/VA Health Care/CAHMP-VA

Indian Health Service

State-Sponsored Health Plan

Other Government Program

CARD HIQ2

CARD HOQ1

A city water supply (also known as a public or community water system) through underground pipes to my home

An individual or private well

Rainwater routed into a tank or cistern on my property

A spring

Something else

CARD FSQ1

Often true

Sometimes true

Never true

CARD INQ

Income earned at a job or business

Retirement or Social Security

Disability, or survivor pension

Unemployment or worker's compensation

Veteran's Administration payments

Child support

Alimony

Interest income

Dividends from stocks or mutual funds

Income from rental properties, royalties, estates or trusts

CARD INQ1

U. $20,000 - $20,999

V. $21,000 - $21,999

W. $22,000 - $22,999

X. $23,000 - $23,999

Y. $24,000 - $24,999

Z. $25,000 - $25,999

AA. $26,000 - $26,999

BB. $27,000 - $27,999

CC. $28,000 - $28,999

DD. $29,000 - $29,999

EE. $30,000 - $30,999

FF. $31,000 - $31,999

GG. $32,000 - $32,999

HH. $33,000 - $33,999

II. $34,000 - $34,999

JJ. $35,000 - $39,999

KK. $40,000 - $44,999

LL. $45,000 - $49,999

MM. $50,000 - $54,999

NN. $55,000 - $59,999

OO. $60,000 - $64,999

PP. $65,000 - $69,999

QQ. $70,000 - $74,999

RR. $75,000 - $79,999

SS. $80,000 - $84,999

TT. $85,000 - $89,999

UU. $90,000 - $94,999

VV. $95,000 - $99,999

WW. $100,000 and over

CARD INQ2

A. Less than $1,000

B. $1,000 - $1,999

C. $2,000 - $2,999

D. $3,000 - $3,999

E. $4,000 - $4,999

F. $5,000 - $5,999

G. $6,000 - $6,999

H. $7,000 - $7,999

I. $8,000 - $8,999

J. $9,000 - $9,999

K. $10,000 - $10,999

L. $11,000 - $11,999

M. $12,000 - $12,999

N. $13,000 - $13,999

O. $14,000 - $14,999

P. $15,000 - $15,999

Q. $16,000 - $16,999

R. $17,000 - $17,999

S. $18,000 - $18,999

T. $19,000 - $19,999

CARD INQ3

Cash Checking accounts

Saving accounts

CDs (Certificates of deposit)

Retirement accounts (such as IRAs, 401K, etc.)

Stocks

Bonds

Mutual funds

CARD INQ4

A: $0 - $3,000

B: $3,001 - $5,000

C: $5,001 - $10,000

D: $10,001 - $15,000

E: $15,001 - $20,000

6e-47