[p. 165]
M. DOCTOR SERVICE PAGE
Refer to "2-Week Doctor Visits Page," and complete for each visit, or mark box.
Person number
M1
Refer to question 2 on 2-Week Doctor Visits Page and mark appropriate box.
2[] Home visit (Next DR visit)
8[] Other (1)
Hand calendar.
Refer to questions 1 and 2 on "2-Week Doctor Visits Page" for date and type of health care facility.
1a. Earlier you told me that during the two weeks outlined in red on that calendar, -- received health care [on (date) last week/the week before last]. In what city, county, and State is the (place in 2) located?
County ____
State ____
b. How long did it take for -- to get the this (place) this time?
c. Which letters explain why -- went to this (place) this time?
Hand Card M.
CARD M
B. Especially good for treating this condition
C. Convenient to home
D. Convenient to work/shopping
E. Referred by a doctor
F. Referred by a friend/relative
G. Only place available
H. Health insurance plan requires
I. Emergency
J. Other
Mark all that apply.
1[] B. Especially good for treating this condition
1[] C. Convenient to home
1[] D. Convenient to work/shopping
1[] E. Referred by a doctor
1[] F. Referred by a friend/relative
1[] G. Only place available
1[] H. Health insurance plan requires
1[] I. Emergency
1[] J. Other (Specify)
________
d. Any other reason?
[] No
[p. 166]
M. DOCTOR SERVICE PAGE, Continued
M2
Refer to "BD" box above person's colum
1[] BD box marked (2) [5]
8[] Other (NP)
Hand calendar.
2. Earlier you told me that during the 2 weeks outline in red on that calendar, -- stayed in bed more than half a day because of illness or injury. Did a doctor advise -- to stay in bed during that time?
2[] No
9[] DK