The care of people with diabetes is an important concern of the Public Health Service. Please take a few minutes to answer the following questions on the care you received for your diabetes. Your participation is voluntary and all of your answers will be kept confidential. If you have any questions about this survey, please call Alex Scott at 1-800-945-MEPS (6377). 

This survey should be completed by

NAME: DOB: _____ PID: _____ RUID:

When you have completed the survey, please fold it, seal it with this label, and place it in the envelope provided.

The Agency for Healthcare Research and Quality and The National Center for Health Statistics of the U.S. Public Health Service.  OMB # 0935-0104

A Survey About Your Diabetes Care

Instructions: 
Answer every question by checking one box or filling in a number as indicated. If you are unsure about how to answer a question, please give the best answer you can.

1.	Have you ever been told by a doctor or other health professional that you have diabetes or sugar diabetes? (CHECK ONE)
	Yes	1		Please continue.
	No	2		Thank you for your time.
				This survey is complete.

2.	During 2000, how many times did a doctor, nurse, or other health professional check you for glycosylated hemoglobin or "hemoglobin A-one-C"?   (FILL IN NUMBER OF TIMES)
	Number of Times	____
	Never	96
	Don't Know	98

3.	During 2000, how many times did a health professional check your feet for any sores or irritations? (FILL IN NUMBER OF TIMES)
	Number of Times	____
	Never	96

4.	When was the last time you had an eye exam in which your pupils were dilated? This would have made you temporarily sensitive to bright light. (CHECK ONE)
	During 2001	1
	During 2000	2
	During 1999	3
	Before 1999	4
	Never	5

5.	Has your diabetes caused problems with your kidneys?
	Yes	1
	No	2

6.	Has your diabetes caused problems with your eyes that needed to be treated by an ophthalmologist?
	Yes	1
	No	2

7.	Is your diabetes being treated by modifying your diet?
	Yes	1
	No	2

8.	Is your diabetes being treated by medications taken by mouth?
	Yes	1
	No	2

9.	Is your diabetes being treated with insulin injections?
	Yes	1
	No	2

Thank you for taking the time to 
complete this important survey.

Please remember to fold it, seal it, and place it in the envelope provided. 

If this survey was not completed by the person named on the front page, who completed the survey?

What is this person's relationship to the person named on the front page?

What is the reason the person named on the front page did not complete the survey himself/herself?

This survey is part of the Medical Expenditure Panel Survey, conducted by the U.S. Public Health Service. This survey is authorized under Section 902(a) of the Public Health Service Act [42 U.S.C. 299a]. The confidentiality of personal information is protected by Federal statute, Section 903(c) and Section 308(d) of the Public Health Service Act [42 U.S.C 299a - 1(c) and 242m(d)]. This law prohibits release of personal information outside the public health agencies sponsoring the survey or their contractors without first obtaining permission from the person who gave the information. The Federal government requires that all persons asked to respond to one of its surveys be given the following information: Public reporting burden for this collection of information is estimated to average 5 minutes per interview, the estimated time required to complete the "A Survey About Your Diabetes Care." Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:

Reports Clearance Officer Attention: PRA, United States Public Health Service Paperwork Reduction Project (0935-0098) Hubert H. Humphrey Building, Room 721-B 200 Independence Avenue, SW Washington, DC 20201