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[p.87]

APPENDIX II
ONE-TIME OR SINGLE SUPPLEMENTS: Acute conditions: CY 1973 and 1974


U.S Health Interview Survey Condition Supplement : Medically Attended

a. PSU ____

b. Segment number ____

c. Serial number ____

d. Sample ____

e. Person number ____

f. Sample person

1[] Y
2[] N

g. Name of condition ____

h. Name of person ____

i. Determine if eligible respondent is available:

[] Eligible respondent 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]

Date ____
Beginning time
[] a.m
[] p.m
Ending time
[] a.m
[] p.m
Completed ____

k. Reason for noninterview

1[] Refused
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[] Respondent denies having condition (RA)
[p.88]

1. Please look at the calendar (HAND CALENDAR) and tell me on what date you first noticed (had) the .....

Month ____
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?

1[] Very serious
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?

000[] Discovered by doctor (5)
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 -

A. Did you wait because you couldn't get an appointment or the doctor was not available?
1[] Y
2[] N
B. Because you didn't have the money?
1[] Y
2[] N
C. Because you didn't have a way to get to the doctor?
1[] Y
2[] N
D. Did you wait because you felt the doctor couldn't do anything for the condition?
1[] Y
2[] N
E. Because you felt you could treat the condition yourself?
1[] Y
2[] N
F. Because you didn't want to bother the doctor?
1[] Y
2[] N
G. Did you wait because you didn't think it was serious enough?
1[] Y
2[] N
H. Because you feel uncomfortable with doctors or have a fear of doctors?
1[] Y
2[] N
I. Did you wait for any other reason?
1[] Y
2[] N (K)
Probe if response is inappropriate:
J What was the reason?
1[] ____ (reask I)
2[] ____ (reask I)
Probe if response is inappropriate:
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?
1[] ____
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.

[] Only 1 reason
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?

1[] Y
2[] N (5)

b. Who was this?

1[] Nurse
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____

c. Did you ask anyone else for advice?

[] Y (reask 4b and c)
1[] Nurse
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
[] N

Ask for each column marked in Q.4b
d. Did - - advise you to see a doctor?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

e. Did - - advise you to take some medicine?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

f. Did - - advise you on some other type of treatment?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

g. Did - -give you any other advice?

1[] Nurse
1[] Y
0[] N [Next col]
2[] Druggist
1[] Y
0[] N [Next col]
3[] Relative (Household member)
1[] Y
0[] N [Next col]
4[] Relative (Non-household member)
1[] Y
0[] N [Next col]
5[] Friend
1[] Y
0[] N [Next col]
[] Other- specify ____
1[] Y
0[] N (5)

h. What advice did - - give you?

1[] Nurse ________ [reaskg]
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?

Month ____
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?

0[] While inpatient in hospital (RA)
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?

1[] Y
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?

1[] Another doctor
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?

0[] Y (13)
[] 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?

1[] Y
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?

1[] Another doctor
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?

0[] Y (13)
[] 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?

1[] Y
2[] N (4)

b. Did you have any problem making this appointment?

[] Y
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?

1[] Very 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?

1[] Minutes ________
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?

1[] Much too long
2[] Somewhat too long
3[] Not too long

b. About how long did you have to wait after getting there?

1[] Minutes ________
2[] Hours ________

16. During this visit on (date) did the doctor spend enough time with you or not enough time?

1[] Spent 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]?

1[] Y
2[] N (18)

b. Did or will you go back to see him for this condition?

1[] Y(18)
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 .... ?

1[] Y
2[] N (19)

b. Did you get this medicine?

0[] Y (19)
[] N

c. Why not? ________

19a. During this visit did the doctor refer you to another doctor?

1[] Y
2[] N (28)

b. Did or will you see this other doctor?

1[] Y (28)
2[] N
9[] DK

c. Why not? ________ (28)

20. Had you ever gone to this doctor or place before this call?

1[] Y
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?

1[] Another doctor
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?

0[] Y (23)
[] 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?

1[] Very 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?

1[] Spent 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 .... ?

1[] Y
2[] N (26)

b. Did or will you go in to see him for this condition?

1[] Y (26)
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 .....?

1[] Y
2[] N (27)

b. Did you get this medicine?

0[] Y (27)
[] N

c. Why not? ________

27a. During this call, did this doctor refer you to another doctor?

1[] Y
2[] N (28)

b. Did or will you see this other doctor?

1[] Y (28)
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)?

[] Satisfied (b)
[] Dissatisfied (c)

b. Would you say that you were very satisfied or just somewhat satisfied?

1[] Very satisfied (29)
2[] Somewhat satisfied (d)

c. Would you say that you were very dissatisfied or just somewhat dissatisfied?

4[] Very dissatisfied
3[] Somewhat dissatisfied

d. Why is that? ________

29. Do you still have the .... ?

1[] Y
2[] N

RA Respondent
Show who responded for this supplement. If other than self-respondent, show who responded for him.

1[] Responded for self
Person ________ was respondent

If other than self-respondent, give reason for accepting a proxy.

0[] Under 17
1[] Mentally incompetent
2[] Physically incompetent
I: Type of interview
Show how the information on this supplement was obtained

1[] Completed during initial interview
2[] Completed by return visit
3[] Completed by a telephone callback
GO TO A5, CONDITION PAGE

[p.93]


US Health Interview Survey: Condition Supplement
(Nonmedically Attended)

a. PSU ____

b. Segment number ____

c. Serial number ____

d. Sample ____

e. Person Number ____

f. Sample person

1[] Y
2[] N

g. Name of condition ____

h. Name of person ____

i. Determine if eligible respondent is available:

[] Eligible respondent 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]

Date ____
Beginning time
[] a.m
[] p.m
Ending time
[] a.m
[] p.m
Completed ____

k. Reason for noninterview

1[] Refused
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[] Respondent denies having condition (RB)
1. Please look at the calendar (HAND CALENDAR) and tell me on what date you first notices (had) the .....

Month ____
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?

1[] Very serious
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?

1[] Y
2[] N (4)

b. Who was this?

1[] Nurse
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____

c. Did you ask anyone else for advice?

[] Y (reask 3b and c)
1[] Nurse
2[] Druggist
3[] Relative (Household member)
4[] Relative (Non-household member)
5[] Friend
[] Other- specify ____
[] N

Ask for each column marked in Q.3b
d. Did -- advise you to see a doctor?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

e. Did --advise you to take some medicine?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

f. Did -- advise you on some other type of treatment?

1[] Nurse
1[] Y
2[] N
2[] Druggist
1[] Y
2[] N
3[] Relative (Household member)
1[] Y
2[] N
4[] Relative (Non-household member)
1[] Y
2[] N
5[] Friend
1[] Y
2[] N
[] Other- specify ____
1[] Y
2[] N

g. Did -- give you any other advice?

1[] Nurse
1[] Y
0[] N [Next col]
2[] Druggist
1[] Y
0[] N [Next col]
3[] Relative (Household member)
1[] Y
0[] N [Next col]
4[] Relative (Non-household member)
1[] Y
0[] N [Next col]
5[] Friend
1[] Y
0[] N [Next col]
[] Other- specify ____
1[] Y
0[] N (5)

h. What advice did -- give you?

1[] Nurse ________ [reaskg]
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 --?

1[] Y (5b)
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-

A. Did you not see a doctor (did you wait) because you couldn't get an appointment or the doctor was not available?
1[] Y
2[] N
B. Because you didn't have the money?
1[] Y
2[] N
C. Because you didn't have a way to get to the doctor?
1[] Y
2[] N
D. Did you not see a doctor (did you wait) because you felt the doctor couldn't do anything for the condition?
1[] Y
2[] N
E. Because you felt you could treat the condition yourself?
1[] Y
2[] N
F. Because you didn't want to bother the doctor?
1[] Y
2[] N
G. Did you not see a doctor (did you wait) because you didn't think it was serioud enough?
1[] Y
2[] N
H. Because you feel uncomfortable with doctors or have a fear of doctors?
1[] Y
2[] N
I. Did you not see a doctor (did you wait) for any other reason?
1[] Y
2[] N (K)
Probe if response is inappropriate:
J. What was the reason?
1[] ____ (reask I)
2[] ____ (reask I)
Probe if response is inappropriate:
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?
1[] ____
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.

[] Only 1 reason
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?

1[] Y
2[] N

RB Respondent
Show who responded for this supplement. If other than self-respondent, show who responded for him.

1[] Responded for self
Person ________ was respondent

If other than self-respondent, give reason for accepting a proxy.

0[] Under 17
1[] Mentally incompetent
2[] Physically incompetent
I: Type of interview
Show how the information on this supplement was obtained

1[] Completed during initial interview
2[] Completed by return visit
3[] Completed by a telephone callback
GO TO A5, CONDITION PAGE