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dv

[p. 76]

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 3-8 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 the visit (call) did -- actually see (talk to) the doctor?

1 [] Y
2 [] N

6a. Why did he visit (call) the doctor on (date)? Write in reason. ____
Mark appropriate box(es)

1 [] Diag. or treatement (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (7)
4 [] Eye exam. (glasses) (7)
5 [] Immunization (7)
6 [] Other ____ (7)

b. Was this for any specific condition?

[] Y (Enter condition in 6a and change to "Diag. or treatment")
[] N (7)

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

[] Condition reported in 6a

If "Telephone" or "Home" in 3, go to next DV; otherwise ask:
7. In what city (town), county, and State is the (place in 3) located?

City ____
County ____
State ____

8. About how long did it take -- to get to the (place in 3) on (date in 2a)?

Minutes ____

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. 77]


[MK Note: Page 77 appears to be a response sheet for questions asked on page 76. The response area contains three columns to enter information in; only one is represented here since the information contained in each is identical.]

1. Person number ____

2a.

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

b.

[] Y (Reask 2a and b)
[] N (Ask 3-8 for each visit)
3.

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.

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

5.

1 [] Y
2 [] N

6a. ____

1 [] Diag. or treatement (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care (7)
4 [] Eye exam. (glasses) (7)
5 [] Immunization (7)
6 [] Other ____ (7)

b.

[] Y (Enter condition in 6a and change to "Diag. or treatment")
[] N (7)

c. ____

[] Condition reported in 6a

7.

City ____
County ____
State ____

8. Minutes ____


[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.