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dv

[p. 68]

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?

Month ____
Date ____

OR

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? ____