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dv
[p. 152]

E. 2-WEEK DOCTOR VISITS PROBE PAGE

Read to respondent(s):
These next questions are about health care received during the 2 weeks outlined in red on that calendar.

E1
Refer to age

[] Under 14 (1b)
[] 14 and over (1a)
1a. During those 2 weeks, how many times did -- see or talk to a medical doctor? (Include all types of doctors, such as dermatologists, psychiatrists, and ophthalmologists, as well as general practitioners and osteopaths.) (Do not count times while an overnight patient in a hospital.)

00 [] None (NP)
Number of times ____ (NP)

b. During those 2 weeks, how many times did anyone see or talk to a medical doctor about --? (Do not count times while an overnight patient in a hospital.)

00 [] None (NP)
Number of times ____ (NP)

2a. (Besides the time(s) you just told me about) During those 2 weeks, did anyone in the family receive health care at home or go to a doctor's office, clinic, hospital or some other place? Include care from a nurse or anyone working with or for a medical doctor. Do not count times while an overnight patient in a hospital.)

[] Yes
[] No (3a)

b. Who received this care? Mark "DR Visit" box in person's column. ____

[] DR Visit

c. Anyone else?

[] Yes (Reask 2b and c)
[] No

Ask for each person with "DR Visit" in 2b:
d. How many times did -- receive this care during that period?

Number of times ____

3a. (Besides the time(s) you already told me about) During those 2 weeks, did anyone in the family get any medical advice, prescriptions or test results over the PHONE from a doctor, nurse, or anyone working with or for a medical doctor?

[] Yes
[] No (E2)

b. Who was the phone call about? Mark "Phone call" box in person's column. ____

[] Phone call

c. Were there any calls about anyone else?

[] Yes (Reask 3b and c)
[] No

Ask for each person with "DR Visit" in 3b:
d. How many telephone calls were made about --?

Number of calls ____

E2
Add numbers in 1, 2d, and 3d for each person. Record total number of visits and calls in "2-WK. DV" box in Item C1.

[p. 153]

2 WEEK DOCTOR VISITS PAGE

Refer to C1, "2-WK. DV" box.

F1
Refer to age

[] Under 14 (1b)
[] 14 and over (1a)

DR VISIT 1
Person Number ____

1a. On what (other) date(s) during those 2 weeks did -- see or talk to a medical doctor, nurse or doctor's assistant?

Month ____
Date ____
OR
7777 [] Last week
8888 [] Week before

b. On what (other) date(s) during those 2 weeks did anyone see or talk to a medical doctor, nurse, or doctor's assistant about --?

Month ____
Date ____
OR
7777 [] Last week
8888 [] Week before

Ask after last DR visit column for this person:
c. Were there any other visits or calls during that period? Make necessary corrections to 2-Wk. DV box in C1.

1[] Yes (Reask 1a or b and c)
2[] No (Ask 2-5 for each visit)

2. Where did -- receive health care on (date in 1), at a doctor's office, clinic, hospital, some other place, or was this a telephone call?
If doctor's office: Was this office in a hospital?
If hospital: Was it the outpatient clinic or the emergency room?
If clinic: Was it at a hospital outpatient clinic, a company clinic, a public health clinic, or some
other kind of clinic?
If lab: Was it this lab in a hospital?
What was done during this visit (Footnote)

01[] Telephone

Not in hospital:
02 [] Home
03 [] Doctor's office
04 [] Co. or Ind. clinic
05 [] Other clinic
06 [] Lab
07 [] Other (Specify) ____
Hospital:
08 [] O.P Clinic
09 [] Emergency room
10 [] Doctor's office
11 [] Lab
12 [] Overnight patient (Next DR visit)
88 [] Other (Specify)

Ask 3b if under 14.
3a. Did -- actually talk to a medical doctor?

1 [] Yes (3f)
2 [] No (3c)
8 [] DK if M.D. (3c)
9 [] DK who was seen (3f)

b. Did anyone actually talk to a medical doctor about --?

1 [] Yes (3f)
2 [] No (3c)
8 [] DK if M.D. (3c)
9 [] DK who was seen (3f)

c. What type of medical person or assistant was talked to? ____

99 [] DK

d. Does the (entry in 3c) work with or for ONE doctor or MORE than one doctor?

1 [] One (3f)
2 [] More
3 [] None (4)
9 [] DK

e. For this [visit/call] what kind of doctor was the (entry in 3c) working with or for -- a general practitioner or a specialist?

1 [] GP (4)
2 [] Specialist (3g)
9 [] DK (4)

f. Is that doctor a general practitioner or a specialist?

1 [] GP (4)
2 [] Specialist (3g)
9 [] DK (4)

g. What kind of specialist? ____

Ask 4b if under 14.
4a. For what condition did -- see or talk to the [doctor/(entry in 3c)] on (date in 1)? Mark first appropriate box.

1 [] Condition (Item C2, THEN 4g)
2 [] Pregnancy (4e)
3 [] Test(s) or examination (4c)
8 [] Other (Specify) ____ (4g)

b. For what condition did anyone see or talk to the [doctor/(entry in 3c)] on (date in 1)? Mark first appropriate box.

1 [] Condition (Item C2, THEN 4g)
2 [] Pregnancy (4e)
3 [] Test(s) or examination (4c)
8 [] Other (Specify) ____ (4g)


c. Was a condition found as a result of the [test(s)/examination]?

[] Yes (4h)
[] No

d. Was this [test/examination] because of a specific condition -- had?

[] Yes (4h)
[] No (4g)

e. During the past 2 weeks was -- sick because of her pregnancy?

[] Yes
[] No (4g)

f. What was the matter? ________ (item C2, THEN 4g)

g. During this [visit/call] was the doctor/(entry in 3c)] talked to about any (other) condition?

[] Yes
[] No (5)

h. What was the condition? ____ (Item in C2, THEN 4g)

[] Pregnancy (4e)

Mark box if "Telephone" in 2.
5a. Did -- have any kind of surgery or operation during this visit, including bone settings and stitches?

0 [] Telephone in 2 (Next DR visit)
1 [] Yes
2 [] No (Next DR visit)

b. What was the name of the surgery or operation? If name of operation not known, describe what was done.

(1) ____
(2) ____

c. Was there any other surgery or operation during this visit?

[] Yes (Reask 5b and c)
[] No