[p. 67]
MEDICAL CARE PAGE (SAMPLE PERSONS ONLY)
1. Is there ONE particular doctor or place , usually goes to when he is sick or when you need advice about his health?
2 [] N (11)
2a. Where do you go for this care or advice for, to a clinic, hospital, doctor's office, or some other place?
If Hospital: Is this an outpatient clinic or the emergency room?
If Clinic: Is this a hospital outpatient clinic, a company clinic, or some other kind of clinic?
2 [] Home (5)
3 [] Doctor's clinic (2b)
4 [] Group practice (3)
5 [] Hospital Outpatient Clinic (3)
6 [] Hospital Emergency Room (3)
7 [] Company or Industry Clinic (3)
[] Other (Specify) ____ (3)
b. Is this a group practice clinic , that is, does it consist of three or more doctors who share the same equipment?
2 [] N
9 [] DK
3a. What is the name of this (place)? ____
b. During the past 12 months, that is, since (date) a year ago, how many times did you see or talk to a doctor at this place about ,?
000 [] None
c. If something bothered you about ,'s health, would you first go to (name of place), or would you try to determine what was wrong and go to the type of place most appropriate for this kind of trouble?
2 [] Select most appropriate place
[] Other (Specify) ____
4a. Is there a PARTICULAR doctor , usually sees at (name of place)?
2 [] N (M1)
b. Is this doctor a general practitioner or a specialist?
[] Specialist - What kind of specialist is he? ____ (M1)
5a. What is the name of this doctor? ____
b. During the past 12 months, that is, since (date) a year ago, how many times did you see or talk to (name of doctor) about ,?
000 [] None
c. Is this doctor part of a group practice , that is, does he work with two or more other doctors and share the same equipment?
2 [] N
9 [] DK
6. Is this doctor a general practitioner or a specialist?
[] Specialist - What kind of specialist is he? ____
[p. 68]
7. If something bothered you about ,'s health, would you first go to (name of doctor), or would you try to determine what was wrong and select the most appropriate specialist?
2 [] Select most appropriate specialist
[] Other (Specify) ____
M1
Refer to "12 Mo. DV" box at top of person's column and mark as appropriate:
2 [] No 12-month DV (17)
[MK Note: End section M1]
8a. (Besides (name of doctor)) During the past 12 months has , seen a (any other) doctor at a private doctor's office?
2 [] N (9)
b. During that period, how many (other) doctors has , seen at a private doctor's office?
Doctors ____ (8d)
c. Did (name of doctor/place) EVER refer , to this doctor?
2 [] N (9)
d. Did (name of doctor/place) EVER refer , to ANY of these other doctors?
2 [] N (9)
e. Did (name of doctor/place) refer , to ALL of these other doctors?
2 [] N
9. During the past 12 months has , seen a doctor at (any of the following places) ,
2 [] N (9b)
2 [] N (9c)
2 [] N (9d)
2 [] N (9e)
2 [] N (10)
[MK Note: The following question is part of question 9 that is asked if the respondent answers "Yes" to 9a-e. There are 5 separate rows for responses that correspond to each of the five locations contained in question 9.]
2 [] N
10a. During the past 12 months has , seen a doctor at any other type of place? (Do not include doctors seen while a patient in a hospital.)
2 [] N (14)
b. What type of place was this? ____
[MK Note: Question 10b has two rows for responses that contain the same information.]
Type of place ____ (Col. 1)
2 [] N (Reask 10a)
[p. 69]
11. Many people do not have ONE particular doctor. (Hand Card D) Which of those statements best describes why you don't have one particular doctor or place for medical care for ,?
1. Haven't needed a doctor.
2. Haven't been able to find the right doctor.
3. Go to a number of different doctors depending upon what is wrong.
4. Other reason.
[] 2
[] 3
[] Other (Specify) ____
M2
Refer to "12 Mo. DV" box at top of person's column and mark as appropriate:
2 [] No 12 Month DV (17)
[MK Note: End section M2]
12. During the past 12 months, has , seen a doctor at any of the following places -
2 [] N
2 [] N
2 [] N
2 [] N
2 [] N
2 [] N
13a. During the past 12 months, has , seen a doctor at any other type of place? (Do not include doctors seen while a patient in a hospital.)
2 [] N (14)
b. What type of place was this?
[Response repeated 1x]
14. During the past 12 months did you get medical advice for , from ANY doctor over the telephone?
2 [] N
15. During the past 12 months has ANY doctor come to your home to give , medical care?
2 [] N
CARD H
2. Social Security Medicare.
3. Health Insurance.
4. Workmen's Compensation
5. Accident insurance carried by family or someone outside the family.
6. Armed Forces Dependent Care (CHAMPUS).
7. Veteran's benefits.
8. Medicaid.
9. Welfare.
10. Professional courtesy.
11. Other source.
16a. During the past 12 months, which of those sources paid any part of ,'s doctor bills?
[] 2
[] 3
[] 4
[] 5
[] 6
[] 7
[] 8
[] 9
[] 10
[] Other (Specify) ____
b. During that period, did any other source pay any part of his doctor bills?
[] N
If "1" is circled in 16a, go to 17; otherwise ask:
c. During the past 12 months, did you or your family pay any part of ,'s doctor bills?
2 [] N
[p. 70]
17. During the past 12 months, have you had any problems getting medical care for , (for any of the following reasons) ,
2 [] N (17b)
2 [] N (17c)
2 [] N (17d)
2 [] N (17e)
2 [] N (18)
[MK Note: The following question accompanies questions 17a-e and has 5 separate rows for responses that correspond to questions 17a-e; only one response row is represented here. This question is only asked if the response is "Yes" in questions 17a-e.]
2 [] N
[MK Note: The following question accompanies questions 17a-e and has 5 separate rows for responses that correspond to questions 17a-e; only one response row is represented here.]
2 [] N
18. During the past 12 months, have you had any problem getting an appointment for , as soon as you felt he needed one?
2 [] N (19)
2 [] N
2 [] N
19a. During the past 12 months, have you had any other problem getting medical care for ,?
2 [] N (20)
[MK Note: Question 19b has two rows for responses; only one response row is represented here since they contain identical information.]
b. What problem did you have? ________ (Col. 1)
2 [] N
2 [] N (Reask 19a)
20a. In general do you feel , is getting as much medical care as he needs?
2 [] N
b. Which of those statements describes why , isn't getting enough medical care? Any other reason?
1 [] Health care is too expensive.
2 [] Have problems getting to and from the doctor.
3 [] Can't get appointments when wanted.
4 [] Office hours are inconvenient.
5 [] Doctors never spend enough time with me when I see them.
6 [] Other reason. (Specify) ____
Circle all reasons given
21. During the past 12 months, has , received any services from any of the following persons ,
2 [] N
2 [] N
2 [] N
2 [] N
Show who responded for the Hypertension and Medical Care Pages.
Person ____ was respondent
If other than self respondent, give reason for accepting proxy.
1 [] Mentally incompetent
2 [] Physically incompetent