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[p. 68]


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?

____ Months
____ Date


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 3-6 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?

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. Was the doctor a general practitioner or a specialist?

01[] General practitioner

[] Specialist
What kind of specialist is he? ____

5. During this 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 treatment (6c)
3[] General checkup (6b)
2[] Pre or Postnatal care (Next DV)
4[] Eye exam. (glasses) } (Next DV)
5[] Immunization (Next DV)
6[] Other ____

b. Was this for any specific condition?

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

Mark box or ask:
c. For what condition did -- visit (call) the doctor on (date)?

[] Condition reported in 6a

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.