[p. 76]
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 3-8 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?
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)? Write in reason. ____
Mark appropriate box(es)
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?
[] N (7)
Mark box or ask:
c. For what condition did [sampel person] visit (call) the doctor on (date)? ____
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?
County ____
State ____
8. About how long did it take -- to get to the (place in 3) on (date in 2a)?
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.]
Date ____
OR
7777 [] Last week
8888 [] Week before
b.
[] N (Ask 3-8 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 (7)
4 [] Eye exam. (glasses) (7)
5 [] Immunization (7)
6 [] Other ____ (7)
b.
[] N (7)
c. ____
County ____
State ____
[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.