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[p. 55]


[MK Note: There are two columns to fill in information for Doctor Visit (1) and Doctor Visit (2). The same information is included in both columns.]


1. Person number ____

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 ____
[] Last week
[] Week before

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

[] Yes (Reask 2a and b)
[] No (As 3-8 for each visit)

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

If Hospital: Was it the out-patient clinic, or the emergency room?

If Clinic: Was it a hospital out-patient clinic, a company clinic, or some other kind of clinic?

xo [] While inpatient in hospital (STOP)
01 [] Doctor's office
10 [] Telephone (7)
20 [] Hospital Out-Patient Clinic
30 [] Home (7)
40 [] Hospital Emergency Room
50 [] Company or Industry Clinic
60 [] Other (Specify) ____

4. About how long did it take him to get there for that visit?

Minutes ____
Hours ____

5. Did he have an appointment for that visit?

1 [] Yes
2 [] No

6. Once he got there, about how long did he wait to see the doctor?

Minutes ____
Hours ____
xxx [] DK

7. Is the doctor a general practitioner or a specialist?

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

8a. Why did he visit (call) a doctor on (date)? Write in and mark appropriate box(es). ____

1 [] Diag. or treatment (8b)
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, ask:

b. For what condition did -- visit the doctor on this date? ____