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dv

[p. 67]

2-WEEKS DOCTOR VISITS PAGE

[There are two columns to fill in information for 2-WEEKS DOCTOR VISITS. 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 ____
or
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 3-7 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. Was this visit for emergency care?

1 [] Y
2 [] N

b. Was this visit for surgery or pre or postsurgical care?

1 [] Y
2 [] N

6a. Why did he visit (call) a doctor on (date)? Write in reason. ________

Mark appropriate box(es)

1 [] Diag. or treatment (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (7)
4 [] Eye exam. (glasses) (7)
5 [] Immunization (7)
6 [] Other (7)

b. Was this for any specific condition?

[] Y (Enter condtion in 6a and change to "Diag. or treatment")
[] N (7)

Mark box or ask:

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

[] Condition reported in 6a

Please look at this card (Show Card H).
Card H

1. Total or partial payment by self or family.
2. Social Security Medicare
3. Hospital insurance or Doctor Visit insurance
4. Workmen's compensation
5. Accident insurance carried by family or someone outside the family
6. Armed Forces Dependent Care (CHAMPUS)
7. Veteran's Benefits
8. Medicaid
9. Welfare
10. Other (Some other source)

7a. Which of those sources did or will pay any of the doctor's bill for this visit on (date)?

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10 (Specify) ____

b. Did or will any other source pay any of the doctor's bill for this visit?

1 [] Y
2 [] N (Next DV)

c. Which source? Circle additional sources in 7a

[p. 68]

12-MONTHS DOCTOR VISITS PAGE

1.

[] 2-week D.V. (NP)
[] No 12-month D.V. (NP)

Earlier, you told me that -- had seen or talked to a doctor during the past 12 months.

2. In what month during the past 12 months did -- last visit or talk to a doctor?

Month ____
Year 19_ _

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

If Hospital: Was it the outpatient clinic or the emergency room?
If Clinic: Was it a hospital outpatient 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 Outpatient 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. Was this visit for emergency care?

1 [] Y
2 [] N

b. Was this visit for surgery or pre or postsurgical care?

1 [] Y
2 [] N

6a. Why did he visit (call) the doctor in (month)? Write in reason ________

Mark appropriate box(es)

1 [] Diag. or treatment (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (7)
4 [] Eye exam. (glasses) (7)
5 [] Immunization (7)
6 [] Other (7)

b. Was this for any specific condition?

[] Y (Enter cond. in 6a, change to "Diag. or treatment")
[] N (7)

Mark box or ask:

c. For what condition did -- visit the doctor in (month)? ____

[] Condition reported in 6a

Please look at this card -- (Show Card H).
Card H

1. Total or partial payment by self or family.
2. Social Security Medicare
3. Hospital insurance or Doctor Visit insurance
4. Workmen's compensation
5. Accident insurance carried by family or someone outside the family
6. Armed Forces Dependent Care (CHAMPUS)
7. Veteran's Benefits
8. Medicaid
9. Welfare
10. Other (Some other source)

7a. Which of those sources did or will pay any of the doctor's bill for this visit?

[] 1
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10 (Specify) ____

b. Did or will any other source pay any of the doctor's bill for this visit?

1 [] Y
2 [] N (NP)

c. Which source? Circle additional sources in 7a