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[p. 66]


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


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 ____
7777 [] Last week
8888 [] Week before

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

[] Y (Reask 2a and b)
[] N (As 3-5 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 (group practice or doctor's clinic)
10 [] Telephone
20 [] Hospital Out-Patient Clinic
30 [] Home
40 [] Hospital Emergency Room
50 [] Company or Industry Clinic
60 [] Other (Specify) ____

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

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

5a. Why did he visit (call) a doctor on (date)? Write in reason. ________
Mark appropriate box(es)

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

b. Was this for any specific condition?

[] Y (Enter condtion in 5a and change to "Diag. or treatment")
[] N (Next DV)

Mark box or ask:
c. For what condition did -- visit the doctor on this date? ____

[] Condition reported in 5a