Medical Expenses and Utilization Topical Module Questionnaire

______________________________________________________________
>ME01<

These next few questions are about your health. Would you say your health in general is
excellent, very good, good, fair, or poor?

[1] Excellent
[2] Very good
[3] Good
[4] Fair
[5] Poor

______________________________________________________________
>ME02<

During the past 12 months, that is, the period from today back to this date one year ago, were
you a patient in a hospital overnight or longer?

[1] Yes
[2] No

______________________________________________________________
>ME03<

How many nights in all did you spend in a hospital of any type during the past 12 months?

ENTER "N" FOR NONE OR NO TIMES

-------- nights

______________________________________________________________
>ME04<

Which of the following best describes the reasons why you entered the hospital during the most
recent stay of one night or longer.

FR NOTES: READ ALL ANSWER CATEGORIES BELOW .

(1) Yes - applies (2) No - does not apply

___ Diagnostic tests to determine what was wrong?
___ Give birth, including cesarean section? (SHOW FOR FEMALE Rs ONLY)
___ Operation or surgery?
___ Treatment or therapy, not including surgery?
___ Any other reason?

______________________________________________________________
>ME05<

During the past 12 months, did you take any prescription medications?

[1] Yes
[2] No

______________________________________________________________
>ME06<

Do you take prescription medicines on a daily basis?

[1] Yes
[2] No

______________________________________________________________
>ME07<

Do you have the flashcard pamphlet we sent you in the mail? It would have come with the introductory letter.
[1] Yes
[2] No

______________________________________________________________
>ME08<

During the past 12 months, how many visits did you make to a dentist or other dental professional such as a hygienist, orthodontist, or oral surgeon?

-------- times

______________________________________________________________
>ME09<

Have you lost any of your permanent adult teeth?

[1] Yes
[2] No

______________________________________________________________
>ME10<

Have you lost all of your permanent adult teeth?

[1] Yes
[2] No

______________________________________________________________
>ME11<

During the past 12 months, how many times did you see or talk to a medical doctor or other
medical provider about your health?

........ times

______________________________________________________________
>ME12<

Did that visit or call include contact with a physician?

[1] Yes
[2] No

______________________________________________________________
>ME13<

About how many of those (FILL IN VALUE FROM >ME11<) visits or calls included contact
with a physician?

..... Times

______________________________________________________________
>ME14<

In the last 12 months, did you purchase any other medical supplies or services such as over the
counter medicines, eyeglasses or contact lenses, diabetic equipment, or transportation services?

[1] Yes
[2] No

______________________________________________________________
>ME15<

During the past 12 months, about how many days did illness or injury keep you in bed more than
half of the day?

ENTER "N" FOR NONE OR NO TIMES

-------- days

______________________________________________________________
>ME16<

During the past 12 months, about how much did pay for health insurance for yourself or others
in the household?

ENTER "N" FOR NO PAYMENTS

__ __ __ __ __ dollars

______________________________________________________________
>ME17<

Was it...

(1) less than $500
(2) $500 to $1000
(3) $1000 to $5000
(4) $5000 to $10000
(5) $10000 or more

______________________________________________________________
>ME18<

During the past 12 months, about how much was paid for your own medical care, including payments for hospital visits, medical providers, dentists, medicine, or medical supplies?

ENTER "N" FOR NO PAYMENTS

__ __ __ __ __ dollars

______________________________________________________________
>ME19<

Was it...

(1) less than $500
(2) $500 to $1000
(3) $1000 to $5000
(4) $5000 to $10000
(5) $10000 or more

______________________________________________________________

>ME20<
Were these amounts for medical care and health insurance the total cost to your household or did
you get reimbursed by some outside source?

(1) Total Cost
(2) Got Reimbursed
(3) Expects to get reimbursed but has not yet

______________________________________________________________
>ME21<

How much of these expenses were reimbursed?
ENTER "N" FOR NONE
ENTER "A" FOR ALL EXPENSES REIMBURSED

------ dollars

------- % (percent reimbursed if answer given as a percentage )

______________________________________________________________
>ME23<

During the past 12 months, was (child's name) a patient in a hospital overnight or longer?

[1] Yes
[2] No

______________________________________________________________
>ME24<

Which children were in a hospital overnight or longer?

ENTER "A" FOR ALL
ENTER LINE NUMBER OF EACH CHILD

<N> No more

______________________________________________________________
>ME25<

How many nights in all did (child's name) spend in a hospital of any type during the past 12 months?

ENTER "N" FOR NONE OR NO TIMES

.......... nights

______________________________________________________________
>ME26<

Which of the following best describes the reasons why (child's name) entered the hospital during the most recent visit of one night or longer.

FR NOTES: READ ALL ANSWER CATEGORIES BELOW.

(1) Yes - applies (2) No - does not apply

___ Diagnostic tests to determine what was wrong?
___ Give birth, including cesarean section (mother)? (SHOW FOR FEMALE
ONLY)
___ To be born (baby)?
___ Operation or surgery?
___ Treatment or therapy, not including surgery?
___ Any other reason?

______________________________________________________________
>ME27<

During the past 12 months did (child's name) take any prescription medications?

[1] Yes
[2] No

______________________________________________________________
>ME28<

Which children took prescription medications?

ENTER "A" FOR ALL
ENTER LINE NUMBER OF EACH CHILD

<N> No more

______________________________________________________________
>ME29<

Does (child's name) take prescription medicines on a daily basis?

[1] Yes
[2] No

______________________________________________________________
>ME30<

During the past 12 months, did (child's name) visit a dentist, or other dental professional such as a hygienist, orthodonthist, or oral surgeon?

ENTER "H" FOR FLASHCARD KK

[1] Yes
[2] No

Which children visited a Dentist?

ENTER "A" FOR ALL
ENTER LINE NUMBER OF EACH CHILD

<N> No more

______________________________________________________________
>ME32<

During the past 12 months, how many visits did (child's name) make to a dentist?

ENTER "N" FOR NONE OR NO TIMES
ENTER "H" FOR FLASHCARD KK

-------- times

______________________________________________________________
>ME33<

Dental sealants are special plastic coatings that are painted on the tops of the back teeth to
prevent tooth decay. They are different from fillings, caps, crowns, and fluoride treatments.

Has (child's name) ever had dental sealants painted on his/her teeth?

[1] Yes
[2] No

______________________________________________________________
>ME34<

During the past 12 months, did you or anyone else see or talk to a medical doctor or other
medical provider about (child's name) health?

ENTER "H" FOR FLASHCARD LL

[1] Yes
[2] No

______________________________________________________________
>ME35<

For which children?

ENTER LINE NUMBER OF EACH CHILD

ENTER "A" FOR ALL
ENTER "N" FOR NONE, OR FOR "NO MORE" AFTER LINE ENTRIES

During the past 12 months, about how many times did you or anyone else see or talk to a medical doctor or other medical provider about (child's name) health?

ENTER "N" FOR NONE OR NO TIMES
ENTER "H" FOR FLASHCARD LL

.........times

________________________________________________________________________
>ME37<

Did that visit or call include contact with a physician?

[1] Yes
[2] No

________________________________________________________________________
>ME38<

In the past 12 months, about how many of the visits or calls included contact with a physician?

ENTER "A" FOR ALL VISITS
ENTER "N" FOR NONE

..... Times

______________________________________________________________
>ME39<

In the last 12 months, did you or anyone else buy for (child's name) any other medical supplies
or services such as over the counter medicines, eyeglasses or contact lenses, diabetic equipment, or transportation services ?

ENTER "H" FOR FLASHCARD MM

[1] Yes
[2] No

______________________________________________________________
>ME40<

For which children were purchases made?

ENTER "A" FOR ALL
ENTER LINE NUMBER OF EACH CHILD

<N> No more

______________________________________________________________
>ME41<

We have recorded that your health or condition prevents you from working.

For how long have you been prevented from working? Has it been a year or longer, or has it
been less than a year?

[1] A year or longer
[2] less than a year

______________________________________________________________
>ME42<

Is it likely that you will be able to work at some time in the next 12 months?

[1] Yes
[2] No

end of content rule

Page Last Modified: May 12, 2006

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