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[p. 65]


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?

Month ____
Date ____
7777 [] Last week
8888 [] Week before

b. Were there any other doctor visits for him during that period?

[] Y (Reask 2a and b)
[] 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?

0 [] While inpatient in hospital (Next DV)
1 [] Doctor's office (group practice or doctor's clinic)
2 [] Telephone
3 [] Hospital Outpatient 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?

01 [] General practitioner
[] Specialist -- What kind of specialist is he? ____

5. During this visit (call) did -- actually see (talk to) the doctor?

1 [] Y
2 [] N

6a. Why did he visit (call) a doctor on (date)? Write in reason. ________

Mark appropriate box(es)

1 [] Diag. or treatment (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (P1)
4 [] Eye exam. (glasses) (P1)
5 [] Immunization (P1)
6 [] Other ____ (P1)

b. Was this for any specific condition?

[] Y (Enter condition in 6a and change to "Diag. or treatment")
[] N (P1)

Mark box or ask:
c. For what condition did -- visit (call) the doctor on (date)? ____

[] Condition reported in 6a

If the condition in question 6 is first reported on the DV page, a Condition page is required. If there is no Condition page, enter condition in item C and fill a page for it after completing columns for all required doctor visits.