[p. 108]
EYE CARE PAGE
Complete for each SP
(19+: Self; 17-18: Self or parent; Under 17: Parent)
E1
Refer to Flashcard Booklet
2 [] Eligible resp. available
When people need help or advice about their eyes they go to their regular doctor or someone else who takes care of the eyes. Eye care includes examinations, treatments, and surgery. It also includes fitting or adjusting of contact lenses. Eye care does NOT include visits which were only for adjusting frames.
2. Since (12-month date) a year ago, has -- visited a doctor, eye specialist, or someone else for any type of eye care? Please count times a doctor examined --'s eyes even if the visit was not made only for this purpose.
2 [] N (E3)
3. How many total times since (12-month date) a year ago, has -- visited someone for eye care?
4. How many times did -- visit someone for eye care since the first of (hospital probe month) 1979?
Number ____
5 a. On what date did -- visit someone for eye care (the last time)?
Date ____
OR
7777 [] Last week
8888 [] Week before
b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?
2 [] Optical store
[] Other - Specify ____
c. What is the (name and) address of this (place in 5b)?
Street ____
City ____
State ____
d. Who did -- see at the (place in 5b) on that visit?
Spec. code ____
e. Is (person in 5d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?
2 [] Optometrist (E3)
3 [] Optician (E3)
[] Other - Specify ____
f. Is this person a medical doctor?
2 [] N
9 [] DK
6 a. On what date did -- visit someone for eye care the time before last?
E2
[] Other (E3)
Date ____
OR
7777 [] Last week
8888 [] Week before
b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?
2 [] Optical store
[] Other - Specify ____
c. What is the (name and) address of this (place in 6b)?
Street ____
City ____
State ____
d. Who did -- see at the (place in 6b) on that visit?
Spec. code ____
e. Is (person in 6d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?
2 [] Optometrist (E2)
3 [] Optician (E2)
[] Other - Specify ____
f. Is this person a medical doctor?
2 [] N
9 [] DK
E3
a. Mark first appropriate box
2 [] Present for all questions
3 [] Present for 1+ questions
4 [] Not present
b. Enter person number(s) of person who responded
2 - Optometrist
3 - Optician
4 - M.D. - not ophthalmologist
5 - M.D. - DK type
6 - Not an M.D.
7 - DK if M.D.
2 [] Complete - telephone
3 [] Refused
8 [] Other - Specify ____
[p. 109]
[MK Note: Page 109 appears to be a duplicate of page 108.]
EYE CARE PAGE
Complete for each SP
(19+: Self; 17-18: Self or parent; Under 17: Parent)
E1
Refer to Flashcard Booklet
2 [] Eligible resp. available
When people need help or advice about their eyes they go to their regular doctor or someone else who takes care of the eyes. Eye care includes examinations, treatments, and surgery. It also includes fitting or adjusting of contact lenses. Eye care does NOT include visits which were only for adjusting frames.
2. Since (12-month date) a year ago, has -- visited a doctor, eye specialist, or someone else for any type of eye care? Please count times a doctor examined --'s eyes even if the visit was not made only for this purpose.
2 [] N (E3)
3. How many total times since (12-month date) a year ago, has -- visited someone for eye care?
4. How many times did -- visit someone for eye care since the first of (hospital probe month) 1979?
Number ____
5 a. On what date did --visit someone for eye care (the last time)?
Date ____
OR
7777 [] Last week
8888 [] Week before
b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?
2 [] Optical store
[] Other - Specify ____
c. What is the (name and) address of this (place in 5b)?
Street ____
City ____
State ____
d. Who did -- see at the (place in 5b) on that visit?
Spec. code ____
e. Is (person in 5d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?
2 [] Optometrist (E3)
3 [] Optician (E3)
[] Other - Specify ____
f. Is this person a medical doctor?
2 [] N
9 [] DK
E2
[] Other (E3)
Date ____
OR
7777 [] Last week
8888 [] Week before
b. Where did -- go for that visit - to a doctor's office, an optical store, or some other place?
2 [] Optical store
[] Other - Specify ____
c. What is the (name and) address of this (place in 6b)?
Street ____
City ____
State ____
d. Who did -- see at the (place in 6b) on that visit?
Spec. code ____
e. Is (person in 6d) an ophthalmologist, an optometrist, an optician, or some other kind of doctor or specialist?
2 [] Optometrist (E2)
3 [] Optician (E2)
[] Other - Specify ____
f. Is this person a medical doctor?
2 [] N
9 [] DK
E3
a. Mark first appropriate box
2 [] Present for all questions
3 [] Present for 1+ questions
4 [] Not present
b. Enter person number(s) of person who responded
2 - Optometrist
3 - Optician
4 - M.D. - not ophthalmologist
5 - M.D. - DK type
6 - Not an M.D.
7 - DK if M.D.
2 [] Complete - telephone
3 [] Refused
8 [] Other - Specify ____