[p. 69]
2-Weeks Doctor Visit 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 outpatient clinic or the emergency room?
If Clinic: Was it a hospital outpatient 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. Was the doctor a general practitioner or a specialist?
[] Specialist -- What kind of specialist is he? ____
5. During this 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)
1 [] Diag. or treatment (6c)
3 [] General checkup (6b)
2 [] Pre or Postnatal care
4 [] Eye exam. (glasses) } (Next DV)
5 [] Immunization
6 [] Other ____
b. Was this for any specific condition?
[] N (Next DV)
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.