Form 49 PSAQ

7028
Form Approved
OMB# 0935-0118
Exp. Date 3/31/2027

2024

There are a lot of clinical preventive care services available, such as screening tests for different
types of cancer or heart disease. Not everyone makes the same choices about which tests to
have, when to have a particular test or how often. By answering this questionnaire, you will help
MEPS learn about the different choices different people make about preventive care as well as
how people feel about their general health and health care.

Survey Instructions
 Please answer every question by marking one box "." If you are unsure about how to answer a question,
please give the best answer you can.

 You are sometimes told to skip over some questions in this survey. When this happens you will see
arrows that tell you what questions to answer next, like this:

Yes
No  If No, go to question 3


Next Question

 Your participation is voluntary and your answers will be kept confidential as required by law. If you have any
questions about this booklet, please call Alex Scott at 1-800-945-MEPS (6377).

This Booklet
Should Be
Completed By 

RUID:

REGION:

PID:

NAME:

/

DOB:
MONTH

/
DAY

YEAR

This survey is authorized under 42 U.S.C. 299a. This information collection is voluntary and the confidentiality of your responses to this survey is protected by
Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 42 U.S.C. 242m(d)]. Information that could identify you will not be disclosed
unless you have consented to that disclosure. Public reporting burden for this collection of information is estimated to average 7 minutes per response, the estimated
time required to complete the survey. 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. The data you provide will help AHRQ’s mission to produce evidence to make health care safer, higher quality, more
accessible, equitable, and affordable. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (OMB control number 0935-0118) AHRQ, 5600 Fishers
Lane, Room #07W42, Rockville, MD 20857 or by email at REPORTSCLEARANCEOFFICER@ahrq.hhs.gov.

The Agency for Healthcare Research and Quality of
the U.S. Department of Health and Human Services

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Your Health And Health Choices
START HERE:

1. In general, would you say your health is:
Excellent
Very good
Good
Fair
Poor
2. The following items are about activities you might do during a typical day. Does your health now
limit you in these activities? If so, how much?
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf?
Yes, limited a lot
Yes, limited a little
No, not limited at all
b. Climbing several flights of stairs?
Yes, limited a lot
Yes, limited a little
No, not limited at all

"VR-12: How to create VR-12 scales and PCS/MCS summaries” © 2014 by Trustees of Boston University. All Rights Reserved.
(Questions concerning the VR-12 can be directed to Professor Lewis E. Kazis, Boston University e-mail: lek@bu.edu)

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3. During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health:
a. Accomplished less than you would like as a result of your physical health?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
b. Were limited in the kind of work or other activities as a result of your physical health?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
4. During the past 4 weeks, have you had any of the following problems with your work or other regular
daily activities as a result of any emotional problems (such as feeling depressed or anxious):
a. Accomplished less than you would like as a result of any emotional problems?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
b. Didn't do work or other activities as carefully as usual as a result of any emotional problems?
No, none of the time
Yes, a little of the time
Yes, some of the time
Yes, most of the time
Yes, all of the time
5. During the past 4 weeks, how much did pain interfere with your normal work (including both work
outside the home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
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These questions are about how you feel and how things have been with you during the past 4 weeks.
For each question, please give the one answer that comes closest to the way you have been feeling.
6. How much of the time during the past 4 weeks:
a. Have you felt calm and peaceful?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
b. Did you have a lot of energy?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
c. Have you felt downhearted and blue?
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
7. During the past 4 weeks, how much of the time has your physical health or emotional problems
interfered with your social activities (like visiting with friends, relatives, etc.)?
All of the time
Most of the time
Some of the time
A little of the time
None of the time

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8. The next questions are about how you feel about different aspects of your life. For each one, mark
how often you feel that way.
a. First, how often do you feel that you lack companionship?
Never
Rarely
Sometimes
Often
b. How often do you feel left out?
Never
Rarely
Sometimes
Often
c. How often do you feel isolated from others?
Never
Rarely
Sometimes
Often
9. The following questions ask about how you have been feeling during the past 30 days. For each
question, please mark the box that best describes how often you had this feeling.
During the past 30 days,
about how often did you feel...

All of the
time

Most of the
time

a. nervous?.......................................
b. hopeless?......................................
c. restless or fidgety?........................
d. so sad that nothing could cheer
you up?.........................................
e. that everything was an effort?.......
f.

worthless?.....................................

5

Some of the
time

A little of the
time

None of the
time

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10. The following two questions ask about how you have been feeling in the past 2 weeks.
Over the last 2 weeks, how often have you been
bothered by any of the following problems?

Nearly
every day

More than
half the days Several days

Not at all

a. Little interest or pleasure in doing things..........
b. Feeling down, depressed, or hopeless.............
11. During the past 30 days, how often have you experienced trouble getting to sleep or staying asleep?
Not at all
Once a month
Several times a month
Once a week
Several times a week
Almost every day
12. In the past 30 days, other than the activities you did for work, on average, how many days per week
did you engage in moderate exercise (like walking fast, running, jogging, dancing, swimming, biking,
or other similar activities)?
0
1
2
3
4
5
6
7
13. On average, how many minutes did you usually spend exercising at this level on one of those days?
0
10
20
30
40
50
60 or greater

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Alcohol Use
14. Think about your drinking in the past 12 months. How often do you have a drink containing alcohol?

Never  If Never, go to question 18, page 8
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily



For questions on this page:

One drink means one beer,
one small glass of wine (5 oz.),
or one mixed drink containing
one shot (1.5 oz.) of spirits.

15. How many drinks containing alcohol do you have on a typical day you are drinking?
1 drink
2 drinks
3 drinks
4 drinks
5-6 drinks
7-9 drinks
10 or more drinks
16. How often do you have 4 or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily
17. How often do you have 5 or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
2-3 times a week
4-6 times a week
Daily

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18. In the past 12 months, has a doctor, nurse, or other health care professional asked you how much
and how often you drink alcohol? You may have answered in person, on paper, or on a computer.
Yes
No
19. In the past 12 months, has a doctor, nurse, or other health care professional advised you to cut back
or stop drinking alcohol?
Yes
No

Counseling and Treatment
20. People can get counseling, treatment or medicine for many different reasons, such as:
•
•
•
•
•

For feeling depressed, anxious, or “stressed out”
Personal problems (like when a loved one dies or when there are problems at work)
Family problems (like marriage problems or when parents and children have trouble getting along)
Needing help with drug or alcohol use
For mental or emotional illness

In the last 12 months, did you get counseling, treatment or medicine for any of these reasons?
Yes
No
21. During the past 12 months, was there any time when you felt you needed counseling or treatment
for yourself but didn't get it?
Yes
No
22. In the last 12 months, how much of a problem, if any, was it to get any counseling or treatment you
thought you needed?
A big problem
A small problem
Not a problem
Did not seek counseling in the last 12 months
23. Have you ever worried about your family's financial stability because of your mental health, its
treatment, or lasting effects of that treatment?
Yes
No

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Your Choices about Your Health
24. When was the last time you visited a doctor or nurse for a check-up, follow-up care for an ongoing
problem, or a concern that you have about your health? Do not include times you were hospitalized
overnight or visits to the hospital emergency room.
Within the past 12 months
Within the past one to two years
Within the past two to five years
More than five years ago
Never
25. During the past 12 months, have you had either a flu shot (directly in the arm or into the skin) or a flu
vaccine that was sprayed in your nose?
Yes
No
26. In the past 12 months, has a doctor, nurse, or other health care professional weighed you?
Yes
No
27. About how much do you weigh without shoes?
Weight (pounds)

28. About how tall are you without shoes?
Feet

Inches

29. In the past 12 months, has a doctor, nurse, or other health care professional given you advice about
how to manage your weight, discussed weight loss goals with you, or referred you to a weight loss
program to help with your diet and exercise?
Yes
No
30. Has a doctor, nurse, or other health care professional ever asked you if you smoke or use tobacco?
You may have answered in person, on paper, or on a computer.
Yes
No

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31. In the last 12 months, on average, would you say you smoked cigarettes or used tobacco every day,
some days, or not at all?

Every day
Some days
Not at all  If Not at all, go to question 35



32. In the past 12 months, were you advised by a doctor, nurse, or other health care professional to quit
smoking or quit using tobacco?
Yes
No
33. In the past 12 months, were you advised by a doctor, nurse, or other health care professional to take
a medication to assist you with quitting smoking or using tobacco? Some medications that can be
used are: nicotine gum, patch, nasal spray, inhaler, or prescription medicine.
Yes
No
34. In the past 12 months, has a doctor, nurse, or other health care professional discussed or provided
methods and strategies other than medication to assist you with quitting smoking or using tobacco?
Examples of methods and strategies are: telephone helpline, individual or group counseling, or
program to help stop smoking.
Yes
No
35. In the past 12 months, has your doctor, nurse, or other health care professional asked you about
your mood, such as whether you are anxious or depressed? You may have answered in person,
on paper, or on a computer.
Yes
No
36. During the past 24 months, have you had your blood pressure checked by a doctor, nurse, or
other health care professional?
Yes
No
37. Within the past 5 years, have you had your blood cholesterol checked by a doctor, nurse, or other
health care professional?
Yes
No

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If you are female, continue with the questions on this page.
If you are male, go to the next page.
If Female:
38. In the past 12 months, have you received counseling or information about birth control from a doctor
or other medical care provider?
Yes
No
39. Have you had a hysterectomy or have you ever had cervical cancer?
Yes  If Yes, go to next page
No


40. Within the past 5 years, have you had a Pap or human papillomavirus (HPV) test? A Pap or HPV
test is a routine test in which the doctor takes a cell sample from the cervix with a small stick or
brush, and sends it to the lab.
Yes
No
41. About how old were you the last time you had a Pap or HPV test?
Younger than 35
35 to 44 years old
45 to 54 years old
55 to 64 years old
65 to 74 years old
75 or older
I have never had a Pap or HPV test

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If you are age 40 or older, continue with the questions on this page.
If you are younger than 40, go to question 56 on page 15.
If 40 or older:
42. Have you ever had a pneumonia shot? A pneumonia shot or pneumococcal vaccine is usually only
given once or twice in a person's lifetime.
Yes
No, it was offered to me by a doctor, nurse, or other health care professional but I chose
not to receive it
No, for any other reason
43. Have you had the shingles vaccine? Two shingles vaccines are available: Zostavax® and
Shingrix®. The chicken pox virus causes shingles. Zostavax® has been available since 2006 and
Shingrix® since 2017.
Yes
No, it was offered to me by a doctor, nurse, or other health care professional but I chose
not to receive it
No, for any other reason
44. Is there any medical reason why you cannot take aspirin, such as an allergy, another medication
you take, or other side effect?
Yes  If Yes, go to question 46, page 13
No


45. Has a doctor, nurse, or other health care professional ever discussed with you the use of aspirin to
prevent heart attack or stroke?
Yes
No

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If 40 or older:
46. Have you had colon cancer or your entire colon removed?
Yes  If Yes, go to next page
No


47. Within the past 10 years, have you had a colonoscopy? A colonoscopy test examines the bowel
by inserting a tube into the rectum. After a colonoscopy, you feel tired and usually need someone to
drive you home.
Yes
No, it was offered to me by a doctor, nurse, or other health care professional but I chose
not to receive it
No, for any other reason
48. Within the past 5 years, have you had a sigmoidoscopy? A sigmoidoscopy test also examines
the bowel by inserting a tube into the rectum. You are awake during this test and can drive
yourself home.
Yes
No, it was offered to me by a doctor, nurse, or other health care professional but I chose
not to receive it
No, for any other reason
49. Within the past 12 months, have you had a blood stool test using a home kit? A doctor, nurse, or
other health professional provides you a special kit or cards to use at home to determine whether
the stool contains blood.
Yes
No, it was offered to me by a doctor, nurse, or other health care professional but I chose
not to receive it
No, for any other reason

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If you are 40 or older and female, complete the left side of this page.
If you are 40 or older and male, complete the right side of this page.
If Female & 40 or older
50. Have you ever been told by a doctor, nurse
or other health care professional that you
have osteoporosis? Osteoporosis is when
the bones become fragile and break easily.
Yes  If Yes, go to question 52
No


51. There are several tests to measure bone
density and detect osteoporosis at an early
stage, including a DEXA scan. Have you
ever had your bone density measured?

If Male & 40 or older
54. Have you had prostate cancer?
Yes  If Yes, go to next page
No


55. About how old were you the last time you
had a PSA test? A "P-S-A" is a blood test to
detect prostate cancer. It is also called a
prostate specific antigen test.
Never had a PSA test
Under age 50
Between 51 and 64
Between 65 and 74
75 or older

Yes
No
52. Have you had both breasts removed or
have you ever had breast cancer?

GO TO NEXT PAGE.

Yes  If Yes, go to next page
No


53. Within the past 2 years, have you had a
mammogram? A mammogram is an x-ray
taken only of the breast by a machine that
presses against the breast.
Yes
No

GO TO NEXT PAGE.

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About You
56. What is your age?
Under 18
18 to 39
40 to 49
50 or older
57. What is your current gender?
Female
Male
Non-Binary
I use a different term (specify)
58. What sex were you assigned at birth, for example on your original birth certificate?
Female
Male
59. Which of the following best represents how you think of yourself?
Gay or lesbian
Straight, that is, not gay or lesbian
Bisexual
I use a different term (specify)
I don’t know

  Date completed:

/
MONTH

/
DAY

YEAR

  Who completed this form?
Person named on front of this form
Someone else


If Someone Else, what is person’s relationship to the person named on the front of this form?
Husband or wife
Unmarried partner
Mother, father, or guardian
Son or daughter
Other relative
Not related
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THANK YOU FOR TAKING THE TIME TO COMPLETE THE
QUESTIONNAIRE!


Please give your completed survey to your MEPS interviewer or place
it in the return envelope and mail it back.



If the envelope is missing, mail this survey to:
MEPS
c/o Westat
1600 Research Blvd, RC B16
Rockville, MD 20850

24-233

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