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[p.84]


Department of Health, Education, and Welfare
Public Health Service, Health Resources Administration
Rockville, Maryland 20852

National Center for Health Statistics

Dear Friend,

Your household has just taken part in a health interview conducted by the Bureau of the Census for the US Public Health Service. We greatly appreciate your cooperation in providing us with this information.

Another area of great concern today is the cost of health care in our country. We, therefore, ask you to provide us with information about the amount of money you, your family, and other relatives living with you spent for medical care during 1974 by answering the few questions on this form. Please use any records such as bills, receipts, or check stubs, that would help you in answering the questions. If you cannot supply the exact amounts from your records, give the best estimate you can.

We would appreciate your completing the attached questionnaire within FIVE DAYS, and returning it in the enclosed preaddressed envelope with requires no postage. If a delay cannot be avoided and you cannot answer and return your form during this time, please fill in the information and return it as soon as possible. Since this study is based on a scientific sample of the total population, it is important that each household return a completed questionnaire.

Please be assured that the Bureau of the Census and the U.S Public Health Service hold as confidential all the information you provide. Thus, the results of this voluntary survey will be issued only in the form of statistical totals from which no individual can be identified.

Thank you for your cooperation.

Sincerely yours,
Robert R. Fushsberg
Director
Division of Health Interview Statistics

ASSURANCE OF CONFIDENTIALITY: All information which would permit identification of the individual will be held in strict confidence, will be used only by persons engaged in and for the purposed of the survey, and will not be disclosed or released to others for any purposes.

General Instructions

1. Fill a separate page for the family member whose name is entered at the top. Answer all questions on the page even though the person may not have had any medical or dental expenses in 1974. If the person did not have any expense of a certain kind during 1974, mark the "No bills paid" box. The amounts you give should only include what THIS FAMILY paid, NOT any payments made by health insurance or some other person or agency. IF EXACT AMOUNTS ARE NOT KNOWN, PLEASE ENTER YOUR BEST ESTIMATE.

2. Do not include any amounts paid (or to be paid) by:

Health insurance
Workmen's compensation
Non-profit organizations such as the "Polio Foundation"
Charitable or Welfare Organizations
Military Services
Veterans Administration
Federal, State, City, or County Governments

3. If there are any babies in the household who were born during the past 12 months, the hospitals and doctor bills relating to the baby's birth should be reported on the page for the mother. All other medical expenditures relating to the baby's health should be reported on the page for the baby.

[p.86]

Please answer the following question for:

Person no ________

Dental Bills Paid
1. How much did this family spend on dental bills for this person during 1974, that is, from January 1, 1974 to December 31, 1974?

Include amounts spent for:
Cleanings
Fillings
Straightening
X-rays
Dental Surgery
Extractions
Bridgework
Dental laboratory fees
Other services from a dentist or hygienist
Dollars $ ____Cents ____
or
[] No dental bills paid for this person


Doctor's Bills Paid
2. How much did this family spend on doctor bills for this person during 1974?
Include amounts spent for:

Routine doctors visits
Treatments
Check-ups
Doctor fees while a patient in a hospital
Operations
Deliveries
Pregnancy care
Laboratory fees
Shots
Other services by a medical doctor
Dollars $ ____Cents ____
or
[] No doctor bills paid for this person


Hospital Bills Paid
3. How much did this family spend on hospital bills for this person during 1974?
Include amounts spent for:

Room and board
Operating and delivery rooms
Anesthesia
Tests
X-rays
Special treatments
Any other hospitals services
Dollars $ ____Cents ____
or
[] No hospital bills paid for this person


Payments made for prescription medicine
4. About how much did this family spend on medicine for this person during 1974 that was purchased on a doctor's or dentist's prescription?
Include amounts spent for:

Medicines only if they were prescribed by a doctor or dentist
Dollars $ ____Cents ____
or
[] No prescribed medicines bought for this person


Payments made for eyeglasses, contact lenses or optometrist's bills
5. During the 1974 how much did this family spend on eyeglasses, contact lenses, or optometrists' fees for this person?

Dollars $ ____Cents ____
or
[] No amount paid for these items


Payments made for "other" medical bills
6a. How much did this family spend in other medical expenses for this person during 1974?

Do not include any expenses which you have already recorded. Do not include amounts spent for medicines of any kind.

Include amounts spent for such expenses as:
Chiropractors' or Podiatrists' fees
Hearing aid
Special braces, trusses, wheelchair or artificial limbs
Physical or Speech Therapy
Special nursing care
Nursing Home or Convalescent home care
Dollars $ ____Cents ____
or
[] No amount paid for these items


6b. What type of medical expense did this person have?

Type of medical expense ____


7. Check one of the following boxes

1 [] Referred to records for all dollar amounts entered on this page
2 [] Referred to records for some but not all dollar amounts entered on this page
3 [] Did not refer to any records

[p.87]


Health Insurance
1. During 1974 how much did this family spend on health insurance premiums for plans that pay for any part of a hospital bill or a doctor's bill?
Include:

Amount deducted from paycheck for health insurance premiums
Amount deducted from Social Security Check for Medicare
Amount paid directly to health insurance plans or to Social Security for Medicare

Do not include

Health insurance plans that pay only in the case of accidents
Employer or union contributions
Dollars $____Cents ____
or
[] This family did not pay any insurance premiums

Payments made for Persons not listed on this Questionnaire

2. During the past 12 months, that is, from January 1, 1977 to December 31, 1977 did this family pay any medical expenses for anyone whose name does NOT appear on this questionnaire?
This might include expenses for children now away or school or parents, other relatives or friends now in nursing homes or elsewhere, or who are deceased.

These expenses may include bills from doctors, dentists, optometrists, hospitals, nursing homes, health insurance premiums, cost of prescriptions medicine, eyeglasses and so forth,
Check one box

[] No
[] Yes
Type of Medical Expense Amount This Family Paid
____ Dollars $____ Cents ____
____ Dollars $____ Cents ____
____ Dollars $____ Cents ____


3. Please print below the name of the person or persons who completed this form.

Name ________
Name ________

Note: Before returning this questionnaire, please check to see that you have filled in an answer for EACH question for EACH person listed on the questionnaire, even though the person did not have any medical or dental expenses during 1974.