[p. 78]
2-WEEKS DOCTOR VISITS PAGE
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 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?
[] Specialist -- What kind of specialist is he? ____
5. During the visit (call) did -- actually see (talk to) the doctor?
2 [] N
6a. Why did he visit (call) the doctor on (date)?
Mark appropriate box(es)
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?
[] N (P1)
Mark box or ask:
c. For what condition did -- visit (call) the doctor on (date)? ____
P1
A Condition page is required for the condition in question 6. 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.
[p. 79]
[MK Note: Page 79 appears to be a response sheet for questions asked on page 78. The response area contains three columns to enter information in; only one is represented here since the information contained in each is identical.]
Date ____
OR
7777 [] Last week
8888 [] Week before
b.
[] N (Ask 3-6 for each visit)
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 ____
[] Specialist -- What kind of specialist is he? ____
2 [] N
3 [] General checkup (6b)
2 [] Pre or Postnatal care (P1)
4 [] Eye exam. (glasses) (P1)
5 [] Immunization (P1)
6 [] Other ____ (P1)
b.
[] N (P1)
c. ____
[MK Note: End response sheet]
P1
A Condition page is required for the condition in question 6. 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.