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DOCTOR VISITS PAGE
[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.]
DOCTOR VISIT (1) (2)
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?
Date ____
OR
[] Last week
[] Week before
b. Were there any other doctor visits for him during that period?
[] 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?
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?
Hours ____
5. Did he have an appointment for that visit?
2 [] No
6. Once he got there, about how long did he wait to see the doctor?
Hours ____
xxx [] DK
7. Is the doctor a general practitioner or a specialist?
[] Specialist - What kind of specialist is he? ____
8a. Why did he visit (call) a doctor on (date)? Write in and mark appropriate box(es). ____
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? ____