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pm

[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?

[] Y
[] 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?

[] Y
[] 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?

[] Y
[] 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?

[] Y
[] 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.

[] 1
[] 2
[] 3
[] 4



b. Enter name of medicine ____

[] DK


c. Enter name of condition and reask part (a) of appropriate question. ____


d. Was the [medication] obtained last week or the week before?

1 [] Last week
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?

1 [] Written prescription
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.

Person No. ____


g. During the past 2 weeks, how many different times was this medicine obtained?

Times ____



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.

0000 [] None (j)
9999 [] DK
Dollars $ ____
Cents ____



i. Did or will any other source pay any of the bill for this medicine?

1 [] Y
2 [] N (NM)
9 [] DK (k)



j. What (other) source paid or will pay any part of this medicine?

1 [] Free from doctor (NM)
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?

9999 [] DK
Dollars $ ____
Cents ____