[p. 68]
PRESCRIBED MEDICINES
1a. During the past 2 weeks, (the 2 weeks outlined in red on that calendar) did anyone in the family, (that is you, your --, etc.) buy or obtain any (other) kind of medicine prescribed by a doctor?
[] N (2)
b. What is the name of the medicine? ____
Enter name of medicine in col. (b) of Table M and ask:
What condition is it for? ____ Enter name of condition in col. (c) and reask 1a.
(Besides the prescriptions you have already told me about)
2a. During the past 2 weeks did anyone in the family get any (other) medicine from a pharmacist or drugstore that was prescribed by a telephone call from a doctor?
[] N (3)
b. What is the name of the medicine? ____ Enter name of medicine in col. (b) of Table M and ask:
What condition is it for? ____ Enter name of condition in col. (c) and reask 2a.
(Besides the prescriptions you have already told me about)
3a. During the past 2 weeks did anyone in the family have any (other) prescriptions refilled?
[] N (4)
b. What is the name of the medicine? ____ Enter name of medicine in col. (b) and of Table M and ask:
What condition is it for? ____ Enter name of condition in col. (c) and reask 3a.
(Besides the prescriptions you have already told me about)
4a. During the past 2 weeks did anyone in the family obtain any (other) medicine directly from a doctor to take home?
[] N (Table M)
b. What is the name of the medicine? ____ Enter name of medicine in col. (b) of Table M and ask:
What condition is it for? ____ Enter name of condition in col. (c) and reask 4a.
TABLE M:
Complete columns d-k as appropriate for each prescription listed. If none listed, go to next page.
Line [A-E]
a. Ques. No.
[] 2
[] 3
[] 4
b. Enter name of medicine ____
c. Enter name of condition and reask part (a) of appropriate question. ____
d. Was the [medication] obtained last week or the week before?
2 [] Week before
3 [] In past 2 weeks, DK which
4 [] In interview week (NM)
5 [] Before 2 weeks (NM)
e. How was this medicine obtained -- through a written prescription, a refill, a call to the pharmacist from the doctor, given by the doctor to take home, or was it obtained in some other way?
2 [] Refill
3 [] Call to the pharmacist
4 [] Given by Dr. to take at home
8 [] Dr. recommended (not prescribed)
5 [] Other -- Specify ____
[p. 69]
TABLE M - Continued
f. Who was this prescribed for? ____ Enter appropriate person number.
g. During the past 2 weeks, how many different times was this medicine obtained?
h. How much did or will you or your family pay for this medicine? If two or more times in col. (g), add: Include the total amount for the -- times this medicine was obtained.
9999 [] DK
Dollars $ ____
Cents ____
i. Did or will any other source pay any of the bill for this medicine?
2 [] N (NM)
9 [] DK (k)
j. What (other) source paid or will pay any part of this medicine?
2 [] Private health insurance
3 [] Medicare
4 [] Welfare (incl. Medicaid)
[] Other -- Specify ____
k. What was the total cost of this medicine, including the amount to be paid by all sources?
Dollars $ ____
Cents ____