Form 1 HCE-HealthCare-Eng

Public reporting burden for this collection of information is estimated to average 15 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to,
a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden
estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project
Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 20892-7974, ATTN: PRA (0925-0584). Do not return
the completed form to this address.

OMB#: 0925-0584
Exp. xx/xx/xxxx

HCHS/SOL- Visit 2- Health Care Questionnaire
FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

ADMINISTRATIVE INFORMATION
0a. Completion Date:

0c. Participant Gender:

/

/

0b. Staff ID:

(F=female, M=male)

0e. Does the participant have diabetes?

0d.

Age:

(0=No, 1=Yes)

Instructions: Enter the answer given by the participant for each response. Use the CDART Notelog window to code
'Don’t know/refused' for those questions that do not list these as an option.

A. This first block of questions [Q1-7a] is about health care sought and received
in the preceding 12 months.
1.

2.

In the past 12 months, did you get health care? Select only one answer.
No

0

GO TO QUESTION 8

Yes

1

Refused

8

GO TO QUESTION 8

Don’t Know/ Not Sure 9

GO TO QUESTION 8

What was the reason for seeking health care? (Select all that apply)
a. Annual check-up and/or preventive care
b. Pregnancy-related care
c. Acute care (sudden illness not requiring going to the emergency room)
d. Injury or accident
e. Emergency care
f. Chronic or regular care of a disease (e.g. diabetes, hypertension,
cancer, asthma)
g. Other (Specify: _______________)
h. Refused
i. Don’t know/Not Sure

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:
3.

Most of
the time

Some of
the time

2

SEQ #

None of
the time

a. In the United States mainland

1

2

3

4

b. In Puerto Rico

1

2

3

4

c. In Mexico

1

2

3

4

d. In Canada

1

2

3

4

e. In another country not
mentioned above
(Specify:____________)

1

2

3

4

f.

8

Refused

9

g. Don’t know/Not Sure

5.

0

In the past 12 months, where did you receive your health care?
All the
time

4.

Contact
Occasion

Was there a time in the past 12 months when you needed health care, but could not get it? Select
only one answer.
No

0

Yes

1

Refused

8

GO TO QUESTION 6

Don’t Know/ Not Sure 9

GO TO QUESTION 6

GO TO QUESTION 6

During the last 12 months, were you unable to get any of the following due to financial reasons?
Select all that apply. (Select all that apply.)
a. Prescription medications
b. To go to see a general health care professional
c. To go to see a specialist
d. Surgical procedure
e. Clinical procedure
f. Behavioral therapy, stress management/counseling/mental health services
g. Dental care
h. Eyeglasses
i. I had difficulty getting or affording other service(s)
i1. Specify_____

__

j. Refused
k. Don’t know/Not Sure

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:
6.

Contact
Occasion

0

2

SEQ #

In the past 12 months, how many times did you go to an acute or urgent care center, or
emergency room?
Number of times

6.a.

If = 0, GO TO QUESTION 7

How many of these visits took place in the U.S. mainland? Select only one answer.
All 1
Most 2
Some 3
None 4

7.

In the past 12 months, not counting times you went to an emergency room or urgent care facility,
how many times did you go to a doctor, nurse or other health professional to get care for yourself
for any reason?
Number of times
7.a.

If = 0, GO TO QUESTION 8

How many of these visits took place in the U.S. mainland? Select only one answer.
All 1
Most 2
Some 3
None 4

B. This second block of questions [Q8-10] is about routine medical care.
8.

Do you have one person you think of as your personal doctor or health care provider? Select only
one answer.
No 0
Yes, only one 1
More than one 2
Refused 8
Don’t know/Not Sure 9

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9.

Contact
Occasion

FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

0

2

SEQ #

What kind of place do you USUALLY go to when you need routine or preventive care, such as a
physical examination or check-up?
a. Doesn't get preventive or routine care anywhere

1

b. Doesn't go to one place most often

2

c. Hospital emergency room

3

d. Clinic or health center

4

GO TO QUESTION 11

e. Doctor's office or HMO

5

GO TO QUESTION 11

f. Hospital outpatient department

6

GO TO QUESTION 11

g. Some other place

7

GO TO QUESTION 11

h. Refused

8

GO TO QUESTION 11

i.

9

GO TO QUESTION 11

Specify:

Don't know/Not Sure

10. Why don’t you have a usual source of medical care? (select all that apply)
No
Yes
(Disagree)

(Agree)

a. Doesn't need a doctor/Haven't had any problems

0

1

b. Doesn't like/trust/believe in doctors

0

1

c. Doesn't know where to go

0

1

d. Previous doctor is not available/moved

0

1

e. Too expensive/no insurance/cost

0

1

f. Speak a different language

0

1

g. No care available/Care too far away, not convenient

0

1

h. Put it off/Didn't get around to it

0

1

i. Other (Specify_____________)

0

1

j. Refused

8

k. Don’t know/Not Sure

9

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ID NUMBER:

FORM CODE: HCE
VERSION: 1, 12/18/2013

Contact
Occasion

0

2

SEQ #

C. This third block of questions [Q11-27] is about utilization of screening and
preventive services, and chronic care.
[Some of the questions will be asked to all participants, whereas others will be asked to participants of
specific age, gender or who have specific chronic diseases.]

11. About how long has it been since you had a routine check-up by a doctor or other health
professional? A routine checkup is a general physical exam, not an exam for a specific injury,
sudden illness, or condition. Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

12. About how long has it been since you had a flu vaccination (shot or nasal spray)? Select only one
answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

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Occasion

0

2

SEQ #

13. Have you received the tetanus vaccine for adults (booster)? Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Go To Question 14

Refused

8

Go To Question 14

9
Go To Question 14
Don't know/Not Sure
13 a. If you have received the tetanus vaccine, was that tetanus vaccine combined with the
pertussis or whooping cough vaccine? Select only one answer.
Yes, received the tetanus vaccine combined with the pertussis or
whooping cough vaccine.
Received the tetanus vaccine, but it was not combined with the
pertussis vaccine.
Received the tetanus vaccine, but do not know what type.

1
2
3

14. About how long has it been since you had your vision checked (ability to see) by a doctor or an
optometrist? Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

15. [Men aged 45-79, and Women aged 55-79] Has a doctor or other health professional EVER
told you to take a low-dose aspirin every day or every other day to prevent or control heart
disease? Select only one answer.
No

0

Yes

1

Refused

8

GO TO QUESTION 16

Don't know/Not Sure 9

GO TO QUESTION 16

HCE-HealthCare-12-18-2013.docx

GO TO QUESTION 16

6

FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

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Occasion

0

2

SEQ #

a. Are you NOW following this advice?
No

0
Specify

Yes

1

Refused

8

Don't know/Not Sure

9

16. [Participants aged 50-75 years] Have you had a test to detect colorectal cancer (cancer of the
colon, intestines)? Select only one answer.
No

0

Yes

1

Refused

8

GO TO QUESTION 17

Don't know/Not Sure 9

GO TO QUESTION 17

a. If yes, what test?
a.1.

GO TO QUESTION 17

Specify_______________________,
Date of test:

/

/

(approximate date or year)

17. [Men and women aged 24-32] Have you EVER had an HPV vaccination? Select only one
answer.
No

0

Yes

1

GO TO QUESTION 18

Doctor refused when asked 2

GO TO QUESTION 18

Refused

8

GO TO QUESTION 18

Don't know/Not Sure

9

GO TO QUESTION 18

17.a. How many HPV shots did you receive?

Number of shots

18. [Women aged 40 years and older] How long has it been since you had your last mammogram?
Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago
HCE-HealthCare-12-18-2013.docx

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7

FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

Never

6

Refused

8

Don't know/Not Sure

9

Contact
Occasion

0

2

SEQ #

19. [Women aged 24-65 years] How long has it been since you had your last Pap test (test of
cancer of the cervix)? Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

20. [Women aged 65 years and older] Have you had a test to detect osteoporosis (low density of
the bones)? Select only one answer.
No
0
Yes

1

Refused

8

Don't know/Not Sure 9
21. [Participants with diabetes] About how long has it been since you had your eyes checked, in
which your pupils were dilated, to determine whether diabetes has affected your eyes? Select
only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

22. [Participants with diabetes] About how long has it been since you had a urine test done to
determine whether diabetes has affected your kidneys? Select only one answer.
Within past year (anytime less than 12 months ago)

1

Within past 2 years (1 year but less than 2 years ago)

2

Within past 3 years (2 years but less than 3 years ago) 3
Within past 5 years (3 years but less than 5 years ago) 4
5 or more years ago

5

Never

6

Refused

8

Don't know/Not Sure

9

23. [Participants with diabetes] In the past 12 months, have you checked your feet for any sores or
irritations? Select only one answer.
Never

3

Yes

1

Has no feet

2

GO TO QUESTION 24

Refused

8

GO TO QUESTION 24

Don't know/Not Sure 9

GO TO QUESTION 24

GO TO QUESTION 24

23.a. If yes, how many times? Include times when checked by a family member or friend, but
do NOT include times when checked by a health professional.
23a1.

times per day

23a2.

times per week

23a3.

times per month

24. [Participants with diabetes] In the last 12 months, did a doctor, nurse or other health
professional check your feet for sores or irritations? Select only one answer.
GO TO QUESTION 25

Never

3

Yes

1

Has no feet

2

GO TO QUESTION 25

Refused

8

GO TO QUESTION 25

Don't know/Not Sure 9

GO TO QUESTION 25

24.a. If yes, about how many times?

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

25. [Participants with diabetes] Do you check your blood glucose (sugar)? Select only one answer.
Never

3

Yes

1

Refused

8

GO TO QUESTION 26

Don't know/Not Sure 9

GO TO QUESTION 26

GO TO QUESTION 26

25.a. If yes, how many times? Include the times a friend or family member checked your
blood glucose
25a1.

times per day

25a2.

times per week

25a3.

times per month

26. [Participants with diabetes] A test for hemoglobin A1C measures the average blood glucose
(sugar in the blood) level in the previous 3 months. In the last 12 months, a physician, a nurse or
other health professional checked your hemoglobin A1C? Select only one answer.
No

0

Yes

1

GO TO QUESTION 28

Had never heard of the hemoglobin A1C test 3

GO TO QUESTION 28

Refused

8

GO TO QUESTION 28

Don't know/Not Sure

9

GO TO QUESTION 28

26.a. If yes, how many times?
27. [Participants with diabetes] Do you know your hemoglobin A1c level? Select only one answer.
No

0

Yes

1

Refused

8

Don't know/Not Sure 9

D. This next block of questions [Q28-35] is about health insurance.
28. Do you have health insurance or health care coverage? Select only one answer.
GO TO QUESTION 33

No

0

Yes

1

Refused

8

GO TO QUESTION 33

Don't know/Not Sure 9

GO TO QUESTION 33

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

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Occasion

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2

SEQ #

29. Are you CURRENTLY covered by any of the following types of health insurance or health
coverage plans? Mark "Yes" or "No" for EACH type of coverage in items a – h.
No
Yes
a. Insurance through a current or former employer or union (of this
person or another family member)

0

1

b. Insurance purchased directly from an insurance company (by
this person or another family member)

0

1

c. Medicare, for people 65 and older, or people with certain
disabilities

0

1

d. Medicaid, Medi-Cal, or any kind of government-assistance plan
for those with low income or a disability

0

1

e. Veterans Administration (VA) (including those who have ever
used or enrolled for VA health care)

0

1

f.

0

1

g. Indian Health Service

0

1

h. Any other type of health insurance or health coverage plan
(Specify____________)

0

1

i.

Refused

8

j.

Don’t know/Not Sure

9

TRICARE, CHAMPUS or other military health care plan

30. The health reform law (commonly known as “Obamacare”) establishes new federal and state
marketplaces (also called exchanges) where the uninsured and workers in small businesses can
go to purchase insurance. Have you acquired coverage through one of these new marketplaces
(Covered California; nystateofhealth; HealthCare.gov; CuidadodeSalud.gov)? Select only one
answer.
No

0

Yes

1

Refused

8

Don't know/Not Sure 9
31. In the past 12 months, have you received coverage for medical expenses through Emergency
Medicaid? Select only one answer.
No

0

Yes

1

Refused

8

Don't know/Not Sure 9

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

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Occasion

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2

SEQ #

32. A catastrophic health insurance plan covers 3 annual primary care visits, and only provides
coverage for medical expenses after the individual pays thousands of dollars (for example, the
first $6,000 or more in medical expenses). Have you purchased a catastrophic health insurance
plan? [Note to the interviewers: Catastrophic health plans cover persons younger than age 30
years.] Select only one answer.
No

0

Yes

1

Refused

8

Don't know/Not Sure 9
33. About how long has it been since you last had health insurance coverage? Select only one
answer.
6 months or less

1

More than 6 months, but not more than 1 year 2
More than 1 year, but not more than 3 years

3

More than 3 years

4

Never had insurance

5

Refused

8

Don't know/Not Sure

9

34. What are the main reasons you do not currently have health insurance (check all that apply)?
a. It is too expensive/ the cost is too high
b. I am not eligible for coverage through my employer
c. My employer or my spouse’s/partner’s (or other relative’s) employer does not
offer insurance coverage
d. I was denied insurance coverage due to a previous medical condition
e. I am not eligible for Medicaid or have recently lost my Medicaid coverage
f. I lost the ability to purchase health insurance coverage through my spouse,
partner or other relative
g. I am not eligible for premium tax credits or other tax credits
h. I am not eligible due to my citizenship status
i. I don’t need insurance
j.

I don’t know how to get insurance

k. Other (Specify __________)
l. Refused
m. Don’t know/Not Sure

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

Contact
Occasion

0

2

SEQ #

35. In the past 12 months, have you received coverage for medical expenses through Emergency
Medicaid? Select only one answer.
No

0

Yes

1

Refused

8

Don't know/Not Sure 9
E. The following block of questions [Q36-38] is about place of birth and

citizenship status.
The nature of these questions is sensitive, and some participants may not want to answer them.
Participants should be assured that they may choose not to answer them, and their refusal will not
have any impact on their participation in the study nor will affect any referrals that have already
been schedule. For those participants who choose to answer these questions, assurance about
confidentiality, and that their responses will be blocked and not disclosed to the public should be
underlined.
These questions will be asked to all participants.
36. Where were you born? Select only one answer.
In the U.S.
Specify State:

1

Outside of the U.S
Specify country
Specify city or town

2

37. Are you a U.S. citizen? Select only one answer.
No, not a U.S. citizen

0

Yes, was born in the United States

1

End Questionnaire

Yes, was born in Puerto Rico, Guam, and the U.S. Virgin
Islands or Northern Marianas

2

End Questionnaire

Yes, was born abroad to a U.S. citizen parent or parents

3

End Questionnaire

Yes, is a citizen by naturalization

4

End Questionnaire

Refused

8

End Questionnaire

Don’t know/Not Sure

9

End Questionnaire

Specify year:

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FORM CODE: HCE
VERSION: 1, 12/18/2013

ID NUMBER:

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2

SEQ #

38. If the previous answer is “No”, what of the following situations describes you best? Select only
one answer.
Permanent resident card holder (“Green card” holder)

1

Have applied for a “Green card”

2

Holder of another type of visa

3

Specify:
None of the above

4

Refused

8

Don’t know/Not Sure

9

HCE-HealthCare-12-18-2013.docx

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