[p.87]
APPENDIX II
ONE-TIME OR SINGLE SUPPLEMENTS: Acute conditions: CY 1973 and 1974
U.S Health Interview Survey Condition Supplement : Medically Attended
b. Segment number ____
c. Serial number ____
d. Sample ____
e. Person number ____
f. Sample person
2[] N
g. Name of condition ____
h. Name of person ____
i. Determine if eligible respondent is available:
[] Telephone call or return visit required (AS condition page)
j. Record of telephone calls only
[5 entries in the original document not presented here]
Beginning time
[] p.m
[] p.m
k. Reason for noninterview
2[] Not at home- repeated calls
3[] Temporarily absent
[] Other (Specify) ____
INTRODUCTION: In an interview at your household today (earlier this week) it was reported that you recently had ... The following questions refer to that condition.
1. Please look at the calendar (HAND CALENDAR) and tell me on what date you first noticed (had) the .....
Day ____
2. At that time when you first noticed (had) the ...., how serious did you think it was- very serious, somewhat serious, or not serious at all?
2[] Somewhat serious
3[] Not serious at all
3a. After you first noticed (had) the condition on (date), about how long was it before you visited or talked to a doctor about it?
100[] Under 4 hours (4)
2[] Hours ____
3[] Days ____
4[] Weeks ____
b. We are interested in the various reasons why people wait before going to a doctor. Please tell me whether any of the following statements were reasons why you waited (time) to see or talk to a doctor about this condition -
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N (K)
J What was the reason?
2[] ____ (reask I)
If all "N's" in A-I, ask; otherwise go to Q.3c.
K. Why did you wait (time) to see or talk to a doctor about this .... ? Any other reasons?
2[] ____
If two or more reasons given in statements A-K, ask; otherwise mark box:
c. Which of these reasons would you say was the MAIN reason for waiting to see a doctor for this condition?
Circle the appropriate statement letter in the space to the right.
01[] A
02[] B
03[] C
04[] D
05[] E
06[] F
07[] G
08[] H
09[] J(I)
10[] J(2)
11[] J(3)
12[] J(4)
13[] K(1)
14[] K(2)
15[] K(3)
16[] K(4)
[p.89]
4a. Before you talked to a doctor about this condition, did you ask anyone for advice about it, such as a nurse, druggist, relative, friend or someone else?
2[] N (5)
b. Who was this?
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
c. Did you ask anyone else for advice?
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
Ask for each column marked in Q.4b
d. Did - - advise you to see a doctor?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
e. Did - - advise you to take some medicine?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
f. Did - - advise you on some other type of treatment?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
g. Did - - give you any other advice?
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N (5)
h. What advice did - - give you?
2[] Druggist ________ [reask g]
3[] Relative (Household member) ________ [reask g]
4[] Relative (Non-household member) ________ [reask g]
5[] Friend ________ [reask g]
[] Other- specify ________ [reask g]
5. Please look at the calendar. (Hand Calender). On what date did you first visit or talk to a doctor about this condition?
Date ____
6. On (date) where did you first see or talk to the doctor- at a clinic, hospital, doctor's office, or some other place?
If hospital: Was it a hospital outpatient clinic or the emergency room?
If clinic: was it a hospital outpatient clinic, a company clinic, or some other kind of clinic?
1[] Doctor's office (group practice or doctor's clinic) (7)
2[] Telephone (20)
3[] Hospital outpatient clinic (10)
4[] Home (7)
5[] Hospital emergency room (10)
6[] Company or industry clinic (10)
7[] Other -Specify ________ (10)
7. Had you ever gone to this doctor before this visit?
2[] N
8. How did you choose this doctor - through another doctor, a relative or friend, a medical bureau, from a telephone directory, or in some other way?
2[] Relative/friend
3[] Medical bureau
4[] Telephone directory
[] Other -Specify ____
9a. Is this doctor you visited on (date) the doctor you would usually go to for this type of condition?
[] N
b. Why didn't you use the doctor or place that you would usually go to for this type of condition?______
[p.90]
10. Had you ever gone to this place before this visit?
2[] N
11. How did you choose this place - through another doctor, a relative or friend, a medical bureau, from a telephone directory, or in some other way?
2[] Relative/friend
3[] Medical bureau
4[] Telephone directory
5[] Other - Specify ________
12a. Is this place you visited on (date) the place you would usually go to for this type of condition?
[] N
b. Why didn't you use the doctor or place that you would usually go to for this type of condition?____
If "home" in Q6, go to Q16.
13a. Did you make an appointment for this visit?
2[] N (4)
b. Did you have any problem making this appointment?
0[] N (14)
c. What were the problems? ________
14a. When you visited the doctor on (date), how difficult was it for you to get there - was it very difficult, somewhat difficult, or not at all difficult?
2[] Somewhat difficult
3[] Not at all difficult (c)
b. Why was it difficult? ____
c. About how long did it take you to get there?
2[] Hours ________
15a. After getting there, did you feel that the time you had to wait to see this doctor was much too long, somewhat too long, or not too long?
2[] Somewhat too long
3[] Not too long
b. About how long did you have to wait after getting there?
2[] Hours ________
16. During this visit on (date) did the doctor spend enough time with you or not enough time?
2[] Did not spend enough time
17a. During this visit did the doctor advise you to come back and see him for the [condition]?
2[] N (18)
b. Did or will you go back to see him for this condition?
2[] N
9[] DK
c. Why not? ________
[p. 91]
18a. During this visit on (date) did the doctor prescribe or advise you to get any medicine for this .... ?
2[] N (19)
b. Did you get this medicine?
[] N
c. Why not? ________
19a. During this visit did the doctor refer you to another doctor?
2[] N (28)
b. Did or will you see this other doctor?
2[] N
9[] DK
c. Why not? ________ (28)
20. Had you ever gone to this doctor or place before this call?
2[] N
21. How did you choose this doctor or place- through another doctor, a relative, or friend, a medical bureau, from a telephone directory, or in some other way?
2[] Relative/friend
3[] Medical bureau
4[] Telephone directory
[] Other - Specify ________
22a. Is this doctor or place you called on (date) the doctor or place you would usually go to for this type of condition?
[] N
b. Why didn't you use the doctor or place that you would usually go to for this type of condition?____
23a.How difficult was it for you to reach the doctor by telephone on (date) - was it very difficult, somewhat difficult, or not at all difficult?
2[] Somewhat difficult
3[] Not at all difficult (24)
b. Why was it difficult? ________
24. During this call on (date), did the doctor spend enough time with you or not enough time?
2[] Did not spend enough time
25a. During this call did the doctor advise you to come in and see him for the .... ?
2[] N (26)
b. Did or will you go in to see him for this condition?
2[] N
9[] DK
c. Why not? ________
[p.92]
26a. During this call on (date), did the doctor prescribe or advise you to get any medicine for this .....?
2[] N (27)
b. Did you get this medicine?
[] N
c. Why not? ________
27a. During this call, did this doctor refer you to another doctor?
2[] N (28)
b. Did or will you see this other doctor?
2[] N
9[] DK
c. Why not? ________
28a. In your opinion, were you satisfied or dissatisfied with the treatment or care you received from this doctor on (date)?
[] Dissatisfied (c)
b. Would you say that you were very satisfied or just somewhat satisfied?
2[] Somewhat satisfied (d)
c. Would you say that you were very dissatisfied or just somewhat dissatisfied?
3[] Somewhat dissatisfied
d. Why is that? ________
29. Do you still have the .... ?
2[] N
RA Respondent
Show who responded for this supplement. If other than self-respondent, show who responded for him.
Person ________ was respondent
If other than self-respondent, give reason for accepting a proxy.
1[] Mentally incompetent
2[] Physically incompetent
Show how the information on this supplement was obtained
2[] Completed by return visit
3[] Completed by a telephone callback
[p.93]
US Health Interview Survey: Condition Supplement
(Nonmedically Attended)
b. Segment number ____
c. Serial number ____
d. Sample ____
e. Person Number ____
f. Sample person
2[] N
g. Name of condition ____
h. Name of person ____
i. Determine if eligible respondent is available:
[] Telephone call or return visit required (A5, condition page)
j. Record of telephone calls only
[5 entries in the original document not presented here]
Beginning time
[] a.m
[] p.m
Ending time
[] a.m
[] p.m
Completed ____
k. Reason for noninterview
2[] Not at home-repeated calls
3[] Temporarily absent
[] Other (specify) ____
INTRODUCTION: In an interview at your household today (earlier this week) it was reported that you recently had ....The following questions refer to that condition.
Date ____
2. At that time when you first noticed (had) the ...., how serious did you think it was - very serious, somewhat serious, or not serious at all?
2[] Somewhat serious
3[] Not serious at all
3a. Did you ask anyone for advice about this condition, such as a nurse, druggist, relative,friend or someone else?
2[] N (4)
b. Who was this?
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
c. Did you ask anyone else for advice?
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
Ask for each column marked in Q.3b
d. Did -- advise you to see a doctor?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
e. Did --advise you to take some medicine?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
f. Did -- advise you on some other type of treatment?
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
g. Did -- give you any other advice?
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N [Next col]
0[] N (5)
h. What advice did -- give you?
2[] Druggist ________ [reask g]
3[] Relative (Household member) ________ [reask g]
4[] Relative (Non-household member) ________ [reask g]
5[] Friend ________ [reask g]
[] Other- specify ________ [reask g]
[p.94]
4. Do you expect to see or talk to a doctor about this --?
2[] N
9[] DK
5a. We are interested in the various reasons why people do not go to doctors. Please tell me whether any of the following statements were reasons why you didn't see or talk to a doctor about this condition-
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N
2[] N (K)
J. What was the reason?
2[] ____ (reask I)
If all "N's" in A-I, ask; otherwise go to Q.5c.
K. Why did you (not/wait to) see or talk to a doctor about this - -? Any other reason?
2[] ____
If 2 or more reasons given in statements A-K, ask; otherwise mark box:
c. Which of these reasons would you say was the MAIN reason for (not seeing/waiting to see) a doctor for this condition?
Circle the appropriate statement letter in the space to the right.
01[] A
02[] B
03[] C
04[] D
05[] E
06[] F
07[] G
08[] H
09[] J(I)
10[] J(2)
11[] J(3)
12[] J(4)
13[] K(1)
14[] K(2)
15[] K(3)
16[] K(4)
6. Do you still have this condition?
2[] N
RB Respondent
Show who responded for this supplement. If other than self-respondent, show who responded for him.
Person ________ was respondent
If other than self-respondent, give reason for accepting a proxy.
1[] Mentally incompetent
2[] Physically incompetent
Show how the information on this supplement was obtained
2[] Completed by return visit
3[] Completed by a telephone callback