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[p.49]


DOCTOR VISITS PAGE

See questions 18-21a on page 4 and 5

1. Person number ________

Record each date on which a doctor was visited in a separate Question 2a of the doctor visits questions.
Ask and record the answer to question 2b on last set of Doctor visits questions for each person.
Earlier you told me that --had seen or talked to a doctor during the past 2 weeks.
2a. On what dates during that 2 week period did -- visit or talk to a doctor.

[] Month
[] Jan
[] Feb
[] Mar
[] Apr
[] May
[] June
[] July
[] Aug
[] Sep
[] Oct
[] Nov
[] Dec
Day ________

b. Were there any other doctor visits for -- during that period?

[] Yes -reask Q 2a
[] No- ask Q 3-5 for each visits

Item D:
Interviewer check item
Enter the number of Doctor visits reported for each person in question 18-21a on page 4 and 5. If "none" reported for all persons check here.
Fill one doctor visit section for each visit or call reported including additional visits or calls reported in question 2b.

[] None reported. go to person pages
Person No. 01 : Visits ________
Person No.02: Visits ________
Person No. 03: Visits ________
Person No. 04: Visits ________
Person No. 05: Visits ________
Person No. 06: Visits ________

3. Where did --see the doctor on the (date)? Mark one circle.

[] Home
[] Telephone
[] Doctor's office
[] Pre-paid insurance group
[] Hospital emergency room
[] Hospital out-patient clinic
[] Health department
[] Company or industry
[] Other: specify ________

4. How much was the doctor's bill for that visit (call)?
If bill not received, ask:
How much do you expect the doctor's bill to be for that visit (call)?

Dollars ________
Cents ________

5. Is the Doctor a general practitioner or a specialist?

[] General practitioner
[] Specialist
If specialist ask: What kind of specialist is he? ________

Doctor Visits page 2:

1. Person number ________

Record each date on which a doctor was visited in a separate Question 2a of the doctor visits questions.
Ask and record the answer to question 2b on last set of Doctor visits questions for each person.
Earlier you told me that --had seen or talked to a doctor during the past 2 weeks.
2a. On what dates during that 2 week period did -- visit or talk to a doctor>

[] Month
[] Jan
[] Feb
[] Mar
[] Apr
[] May
[] June
[] July
[] Aug
[] Sep
[] Oct
[] Nov
[] Dec
Day ________

b. Were there any other doctor visits for -- during that period?

[] Yes -reask Q 2a
[] No- ask Q 3-5 for each visits

Item D:
interviewer check item
Enter the number of Doctor visits reported for each person in question 18-21a on page 4 and 5. If "none" reported for all persons check here.
Fill one doctor visit section for each visit or call reported including additional visits or calls reported in question 2b.

[] None reported. go to person pages
Person No. 01 : Visits ________
Person No.02: Visits ________
Person No. 03: Visits ________
Person No. 04: Visits ________
Person No. 05: Visits ________
Person No. 06: Visits ________

3. Where did --see the doctor on the (date)? Mark one circle.

[] Home
[] Telephone
[] Doctor's office
[] Pre-paid insurance group
[] Hospital emergency room
[] Hospital out-patient clinic
[] Health department
[] Company or industry
[] Other: specify ________

4. How much was the doctor's bill for that visit (call)?
If bill not received, ask:
How much do you expect the doctor's bill to be for that visit (call)?

Dollars ________
Cents ________

5. Is the Doctor a general practitioner or a specialist?

[] General practitioner
[] Specialist
If specialist ask: What kind of specialist is he? ________