[p. 60]
2 -- WEEKS DOCTOR VISITS PAGE
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?
Date ____
OR
7777 [] Last week
8888 [] Week before
b. Were there any other doctor visits for him during that period?
[] N (Ask 3-6 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?
1 [] Doctor's office (group practice or doctor's clinic)
2 [] Telephone
3 [] Hospital Out-Patient Clinic
4 [] Home
5 [] Hospital Emergency Room
6 [] Company or Industry Clinic
7 [] Other -- Specify ____
4. Is the doctor a general practitioner or a specialist?
[] Specialist -- What kind of specialist is he? ____
5. During this visit (call) did -- actually see (talk to) the doctor?
2 [] N
6a. Why did he visit (call) a doctor on (date)? Write in reason. ________
Mark appropriate box(es)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (S1)
4 [] Eye exam. (glasses) (S1)
5 [] Immunization (S1)
6 [] Other ____ (S1)
b. Was this for any specific condition?
[] N (S1)
Mark box or ask:
c. For what condition did -- visit (call) the doctor on (date)? ____
S1
Mark one box in each DV column
1 [] Not SP or SP und. 17 (Next DV)
2 [] Eligible resp. avail. (7)
3 [] Return call required (Next DV)
[MK Note: End section S1]
(Earlier, I was told that you had seen a doctor during the past 2 weeks.)
7a. During this visit on (date) was your blood pressure taken?
2 [] N (Next DV)
b. Were you told that your reading was high, low, normal, or were you not told?
2 [] Low
3 [] Normal
4 [] Not told
[] Other (Specify) ____
c. Were you told what the numerical reading was?
2 [] N (Next DV)
d. What was the numerical reading?
[] DK