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Medicare Health Outcomes Survey (HOS)
Questionnaire (English)
2024HOS 3.1
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. Your answers are very important to us. If you are
unable to complete this survey, a family member or “proxy” can fill out the survey about 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
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by
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Be sure to read all the answer choices given before marking a box with an ‘X’.
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by
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:
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stops: Not at 5"
1
Yes Go to Question 3235
2
No Go to Question 3336
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by
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paragraphs of the same style
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 him or herself.
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by
All information that would permit identification of any person who completes this survey is protected by
the Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA). This information
will be used only for purposes permitted by law and will not be disclosed or released for any other
reason. If you have any questions or want to know more about the study, please call [survey vendor
name] at [phone number].
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“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. TheThe valid OMB control number for this information collection is 0938-0701. 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 212441850..”
OMB 0938-0701 Version 02-1 (Expires: 5/31/2025XX/XX/XXXX)
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© 2024© 2021 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.
Items 1–9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.
Medicare Health Outcomes Survey
1. In general, would you say your health is:
Excellent
2
Very good
3
Good
4
Fair
1
No, none of the time
5
Poor
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
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?
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
1
Yes, limited a lot
2
Yes, a little of the time
2
Yes, limited a little
3
Yes, some of the time
3
No, not limited at all
4
Yes, most of the time
5
Yes, all of the time
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
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1
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?
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b. Didn't do work or other activities as
carefully as usual as a result of any
emotional problems
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1
No, none of the time
2
Yes, a little of the time
3
Yes, some of the time
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Yes, most of the time
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5
Yes, all of the time
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5. During the past 4 weeks, how much did
pain interfere with your normal work
(including both work outside the home and
housework)?
1
Not at all
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2
A little bit
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3
Moderately
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Quite a bit
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Extremely
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
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?
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c. Have you felt downhearted
and blue?
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1
All of the time
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2
Most of the time
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3
A good bit of the time
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Some of the time
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1
All of the time
5
A little of the time
2
Most of the time
6
None of the time
3
A good bit of the time
4
Some of the time
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5
A little of the time
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None of the time
b. Did you have a lot of energy?
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1
All of the time
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2
Most of the time
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3
A good bit of the time
4
Some of the time
5
A little of the time
6
None of the time
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
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
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2
Most of the time
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3
Some of the time
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4
A little of the time
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5
None of the time
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Now, we’d like to ask you some questions
about how your health may have changed.
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8. Compared to one year ago, how would
you rate your physical health in general
now?
1
Much better
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2
Slightly better
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3
About the same
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4
Slightly worse
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5
Much worse
9. Compared to one year ago, how would
you rate your emotional problems (such
as feeling anxious, depressed, or irritable)
in general now?
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1
Much better
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2
Slightly better
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3
About the same
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4
Slightly worse
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5
Much worse
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
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.
10. 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
1
11. Because of a health or physical problem,
do you have any difficulty doing the
following activities?
Yes, I have difficulty
3
I am unable to do this activity
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a. Preparing meals
1
2
3
No, I do not have difficulty
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li
Yes, I have difficulty
I don’t do this activity
b. Managing money
No, I do not have difficulty
2
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1
2
No, I do not have difficulty
Yes, I have difficulty
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I don’t do this activity
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c. Taking medication as prescribed
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3
b. Dressing
1
No, I do not have difficulty
2
Yes, I have difficulty
1
3
I am unable to do this activity
2
c. Eating
1
No, I do not have difficulty
2
Yes, I have difficulty
3
I am unable to do this activity
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
3
No, I do not have difficulty
Yes, I have difficulty
I don’t do this activity
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These next questions ask about your physical
and mental health during the past 30 days.
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12. Now, thinking about your physical health,
which includes physical illness and injury,
for how many days during the past 30
days was your physical health not
good?
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"30" days. If no days, please enter “0”
days. Your best estimate would be fine.
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days
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13. Now, thinking about your mental health,
which includes stress, depression, and
problems with emotions, for how many
days during the past 30 days was your
mental health not good?
Please enter a number between "0" and
"30" days. If no days, please enter “0”
days. Your best estimate would be fine.
days
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
14. During the past 30 days, for about how
many days did poor physical or mental
health keep you from doing your usual
activities, such as self-care, work, or
recreation?
Please enter a number between "0" and
"30" days. If no days, please enter “0”
days. Your best estimate would be fine.
days
Now we are going to ask some questions
about specific medical conditions.
1115. Are you blind or do you have serious
difficulty seeing, even when wearing
glasses?
1
Yes
2
No
1216. Are you deaf or do you have serious
difficulty hearing, even with a hearing aid?
19. In the past month, how often did memory
problems interfere with your daily activities?
1
Every day (7 days a week)
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2
Most days (5-6 days a week)
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3
Some days (2-4 days a week)
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4
Rarely (once a week or less)
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5
Never
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Has a doctor ever told you that you had:
16. 20. Hypertension or high blood pressure
1
Yes
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2
No
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1
Yes
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2
No
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1317. Because of a physical, mental, or
emotional condition, do you have
serious difficulty concentrating,
remembering, or making decisions?
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1
Yes
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2
No
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1418. Because of a physical, mental, or
emotional condition, do you have
difficulty doing errands alone such as
visiting a doctor’s office or shopping?
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1
Yes
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2
No
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15
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
17.
21. Angina pectoris or coronary artery
disease
1
Yes
2
No
18. 22. Congestive heart failure
1
Yes
2
No
19. 23. A myocardial infarction or heart attack
1
Yes
2
No
20. 24. Other heart conditions, such as
problems with heart valves or the rhythm
of your heartbeat
1
Yes
2
No
21. 25. A stroke
1
Yes
2
No
Has a doctor ever told you that you had:
22. 26. Emphysema, or asthma, or COPD
(chronic obstructive pulmonary disease)
1
Yes
2
No
2327. Crohn’s disease, ulcerative colitis, or
inflammatory bowel disease
25. 29. Diabetes, high blood sugar, or sugar
in the urine
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1
Yes
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2
No
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26. 30. Depression
1
Yes
2
No
27. 31. Any cancer (other than skin cancer)
1
Yes Go to Question 2832
2
No Go to Question 2933
28. 32. Are you currently under treatment for:
a. Colon or rectal cancer
1
2
Yes
No
b. Lung cancer
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1
Yes
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2
No
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
...
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No
No
...
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2
2
...
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Yes
...
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Yes
1
...
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1
24. 28. Osteoporosis, sometimes called thin
or brittle bones
...
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...
c. Breast cancer
1
Yes
2
No
29
33. In the past 7 days, how much did pain
interfere with your day to day activities?
d. Prostate cancer
1
2
Yes
No
e. Other cancer (other than skin cancer)
1
Yes
2
No
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1
Not at all
2
A little bit
3
Somewhat
4
Quite a bit
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5
Very much
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30. 34. In the past 7 days, how often did
pain keep you from socializing with
others?
31.
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1
Never
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3 pt, Tab stops: 0.5", Left
2
Rarely
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3
Sometimes
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4
Often
5
Always
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
35. In the past 7 days, how would you rate
your pain on average?
No pain
00
01
02
03
04
05
06
07
08
09
10
37. In general, compared to other people
your age, would you say that your health
is:
1
1
Excellent
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2
2
Very good
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3
3
Good
4
4
Fair
5
5
Poor
6
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at 0.38"
7
8
9
10 Worst imaginable pain
36. Over the past 2 weeks, how often have
you been bothered by any of the following
problems?
a. Little interest or pleasure in doing
things
1
Not at all
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2
Several days
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3
More than half the days
4
Nearly every day
b. Feeling down, depressed, or hopeless
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1
Not at all
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2
Several days
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3
More than half the days
4
Nearly every day
32
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
33.
38. Many people experience leakage of urine,
also called urinary incontinence. In the
past six months, have you experienced
leaking of urine?
1
Yes Go to Question 3439
2
No Go to Question 3742
34. 39. During the past six months, how
much did leaking of urine make you
change your daily activities or interfere
with your sleep?
35. 40. Have you ever talked with a doctor,
nurse, or other health care provider about
leaking of urine?
1
Yes
2
No
1
A lot
2
Somewhat
2
3
Not at all
1
Yes Go to Question 3843
2
No Go to Question 3843
3
I had no visits in the past 12
months Go to Question 3944
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36. 41. 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
42. 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.
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Yes
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No
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37.
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38.
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43. 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.
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1
Yes
2
No
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3944. 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?
1
Yes
2
No
3
I had no visits in the past 12
months
4045. Did you fall in the past 12 months?
1
Yes
2
No
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After: 3 pt
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After: 3 pt
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
41. 46. In the past 12 months, have you had
a problem with balance or walking?
1
Yes
2
No
43.
48. 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.)
42. 47. 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
2
3
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1
Less than 5 hours
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2
5 – 6 hours
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3
7 – 8 hours
4
9 or more hours
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44.
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49. During the past month, how would you
rate your overall sleep quality?
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Yes
1
Very Good
No
2
Fairly Good
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I had no visits in the past 12
months
3
Fairly Bad
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4
Very Bad
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45. 50. How much do you weigh in pounds
(lbs.)?
lbs.
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51.
Formatted: Font: 5 pt
lbs.
46.
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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
47.
feet
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inches
inches
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Formatted: Font: 9 pt
OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
52.
Are you male or female?
1
2
49.
What is your race? (One or more
categories may be selected)
Male
Female
4853.
Are you Hispanic, Latino/a or
Spanish origin? (One or more categories
may be selected)
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
54.
50.
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01
White
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02
Black or African American
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03
American Indian or Alaska Native
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After: 3 pt, Tab stops: 0.5", Left
04
Asian Indian
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05
Chinese
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06
Filipino
07
Japanese
08
Korean
09
Vietnamese
10
Other Asian
Formatted: Font: 10 pt, Not Raised by / Lowered by
11
Native Hawaiian
Formatted: Indent: Hanging: 0.31", Space After: 3 pt
12
Guamanian or Chamorro
13
Samoan
14
Other Pacific Islander
Formatted: Font: 5 pt
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Before: 6 pt, After: 6 pt, Tab stops: 0.25", Left + Not at
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Lowered by
Formatted: Spanish (Spain)
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After: 3 pt, Tab stops: 0.5", Left
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stops: Not at 0.38"
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
55. What language do you mainly speak
at home?
52. 57. What is the highest grade or level of
school that you have completed?
1
English
1
2
Spanish
2
3
Chinese
4
Russian
3
High school graduate or GED
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After: 3 pt, Line spacing: single
Some other language (please
specify)
4
Some college or 2-year degree
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5
4-year college graduate
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6
More than a 4-year college degree
7
8th grade or less
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Some high school, but did not
graduate
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Line spacing: single
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51. 56. What is your current marital status?
5358. Do you live alone or with others? (One
or more categories may be selected)
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After: 3 pt, Line spacing: single
1
Married
2
Divorced
1
Alone
3
Separated
2
With spouse/significant other
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Widowed
3
Formatted: Not Raised by / Lowered by
4
With children/other relatives
5
Never married
4
With non-relatives
5
With paid caregiver
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
59.
5661. Who completed this survey form?
54. Where do you live?
1
2
3
4
House, apartment, condominium, or
mobile home Go to Question
5560
2
3
4
5
2
Assisted living or board and care
home Go to Question 5560
Nursing home Go to Question
5661
3
Other Go to Question 5661
4
55. 60. Is the house or apartment you
currently live in:
1
1
Owned or being bought by you
Owned or being bought by someone
in your family other than you
Rented for money
Not owned and one in which you live
without payment of rent
None of the above
Person to whom survey was
addressed STOP HERE End
of Survey
Family member or relative of person
to whom the survey was addressed
Go to Question 57
Friend of person to whom the survey
was addressed Go to Question 57
Professional caregiver of person to
whom the survey was addressed
Go to Question 57
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-0.13", Space After: 3 pt
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57.
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After: 3 pt
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Before: 6 pt, After: 6 pt, Tab stops: 0.25", Left
Formatted: Space Before: 0 pt
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After: 3 pt
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OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
62. Did someone help you complete this
survey? If so, please fill in that person’s
name.
DO NOT enter the name of the person to
whom this survey was addressed.
Please print clearly.
First Name: _______________________
Last Name: _______________________
YOU HAVE COMPLETED THE SURVEY.
THANK YOU.
Please use the enclosed prepaid envelope to
mail your completed survey to:
Centers for Medicare & Medicaid Services
c/o Survey Processing
[Insert Survey Vendor
Return Address
Contact Information Here]
If you have questions about this survey,
please contact the survey organization
working with Medicare at [survey vendor
phone number] or [survey vendor email].
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Formatted: Normal, Centered, Line spacing: At least 12 pt,
Tab stops: 0.75", Left + 0.88", Left + 5", Right,Leader: …
+ 5.2", Right + 5.3", Left
Formatted: Font: 9 pt
Formatted: Font: 9 pt
OMB 0938-0701 (Expires: 05/31/2025 XX/XX/XX)
| File Type | application/pdf |
| File Title | Medicare Health Outcomes Survey Questionnaire 3.1 |
| Author | Centers for Medicare and Medicaid Services |
| File Modified | 2024-10-07 |
| File Created | 2024-10-07 |