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[p. 55]


1. Person number ____
First visit ____
Dum __

Record each date on which a doctor was visited in a separate question 2a.

Earlier you told me that -- had seen or talked to a doctor during the past 2 weeks.
2a. On what (other) dates during that 2-week period did -- visit or talk to a doctor?

Month ____
Date ____

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

[] Yes (Reask 2a and b)
[] No (As 3-6 for each visit)

3. Where did he see the doctor on the (date), at a clinic, hospital, doctor's office, or some other place?

x0[] While inpatient in hospital (STOP)
01[] Home
10[] Telephone
20[] Doctor's office
30[] Pre-paid Ins. Group.
40[] Hospital Out-patient Clinic
50[] Hospital Emergency Room
60[] Health Department
70[] Company or industry
80[] Other (Specify) ____

4a. How much was the doctor's bill for that visit (call)?

Dollars ____
Cents ____

If bill not received, ask:
b. 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?

01[] General practitioner
[] Specialist
What kind of specialist is he?

6a. Why did you visit (call) a doctor on (date)?
Write in and mark appropriate box(es). ____

1[] Diag. or treatment (6b)
2[] Pre or Postnatal care (Next DV)
3[] General checkup (Next DV)
4[] Eye exam. (glasses) (Next DV)
5[] Immunization (Next DV)
6[] Other (Next DV)

If 2 or more doctor visits for person and no condition reported in 6a, ask:
b. For what condition did -- visit the doctor on this date?

Write in