NATIONAL ORIGIN
-- Puerto Rican
-- Cuban
-- Mexican, Mexican-American, Mexicano, Chicano
-- Other Latin American
-- Other Spanish
RACIAL BACKGROUND
-- American Indian
-- Aleut, Eskimo
-- Asian or Pacific Islander
-- Black
-- White
-- High Blood Pressure, Toxemia, Pre-Eclampsia, or Eclampsia
-- Anemia
-- Diabetes, Gestational Diabetes, or High Blood Sugar
-- Low Lying Placenta (Placenta Previa)
-- Vaginal Bleeding
-- Premature Labor
-- No Difficulty
-- Some Difficulty
-- A Lot of Difficulty
-- Completely Unable To Do It
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0______________________________________________________________4 |
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| NO PROBLEM | A VERY BIG PROBLEM | |
-- Definitely False
-- Mostly False
-- Mostly True
-- Definitely True
TYPES OF HEALTH CARE PROVIDERS AND FACILITIES
|
Medical Professionals and Practitioners: Medical Doctor
Mental Health Professionals: Psychiatrist |
Medical Facility or Clinic: Health Clinic
Dental Care: Dentist
|
| TYPES OF HOSPITAL SERVICES
Overnight Stay (1 or more nights) |
TYPES OF LONG TERM CARE FACILITIES Convalescent Home |
TYPES OF HOME CARE SERVICES
Skilled Medical Care
Home care from a nurse, any type of therapist, a doctor, a social worker, or anyone else providing nursing or medical care.
Personal Care
Home care services including bathing, dressing, or help getting around the house either paid or unpaid.
Household Chore Services
Help in the home with services like cooking or cleaning either paid or unpaid.
Companionship
Services such as reading, talking, or going for a walk, a drive, or to a restaurant either paid or unpaid.
Any Other Type of Home Care
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses ...
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies ...
Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
TYPES OF DENTAL CARE PROVIDERS
Dentist
Dental or Oral Surgeon
Orthodontist
Dental Hygienist
Dental Technician
Dental Assistant
TYPES OF MEDICAL PROVIDERS
Medical Professionals:
Medical Doctor
Nurse
Nurse Practitioner
Nurse Midwife
Physiatrist
Mental Health Professionals:
Psychiatrist
Psychologist
TYPES OF HOSPITAL SERVICES
Overnight Stay (1 or more nights)
Emergency Room Visit
Outpatient Department Visit
TYPES OF OTHER MEDICAL PROVIDERS
Medical Professionals and Practitioners:
Paramedic
Health Aide
Physician’s Assistant
Midwife
Optometrist/Ophthalmologist
Podiatrist (Foot Doctor)
Chiropractor
Acupuncturist
Therapist - Physical, Speech, Occupational
Audiologist
Medical Facility or Clinic:
Health Clinic
Walk-in Surgi-Clinic
Company or School Clinic
Infirmary
Neighborhood Health Clinic
Family Planning Center
Mental Health Facility
Mental Health Professionals:
Psychiatric Social Worker
Mental Health Therapist
TYPES OF HOME CARE SERVICES
Skilled Medical Care
Home care from a nurse, any type of therapist, a doctor, a social worker, or anyone else providing nursing or medical care.
Personal Care
Home care services including bathing, dressing, or help getting around the house either paid or unpaid.
Household Chore Services
Help in the home with services like cooking or cleaning either paid or unpaid.
Companionship
Services such as reading, talking, or going for a walk, a drive, or to a restaurant either paid or unpaid.
Any Other Type of Home Care
TYPES OF LONG TERM CARE FACILITIES
Convalescent Home
Nursing Home
Nursing Home Unit of a Hospital
Intermediate Care Facilities
Board and Care Homes
Residential Psychiatric Institution
Facility for the Mentally Retarded
Group Homes
Long Term Place that Provides Hospice Care
Long Term Place that Provides Respite Care
TYPES OF OTHER MEDICAL SUPPLIES/EXPENSES
Eyeglasses or Contact Lenses ...
Bought
Replaced
Paid for Repairing
Diabetic Equipment or Supplies ...
Insulin
Syringes
Test Paper
Other Diabetic Equipment or Supplies
-- Operation or Surgical Procedure
-- Treatment or Therapy, Not Including Surgery
-- Diagnostic Tests Only
-- Give Birth To a Baby - Normal or Cesarean Section (Mother)
-- To Be Born (Baby)
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunization or Shots
-- Maternity Care (Pre/Postnatal)
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Maternity Care (Pre/Postnatal)
-- Well Child Exam
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
-- General Checkup
-- Diagnosis or Treatment
-- Emergency (e.g., Accident or Injury)
-- Psychotherapy or Mental Health Counseling
-- Follow-up or Post-Operative Visit
-- Immunizations or Shots
-- Vision Exam
-- Maternity Care (Pre/Postnatal)
-- Well Child Exam
-- Physical Therapy
-- Occupational Therapy
-- Speech Therapy
-- Chemotherapy
-- Radiation Therapy
-- Kidney Dialysis
-- IV Therapy
-- Drug or Alcohol Treatment
-- Allergy Shot
-- Psychotherapy/Counseling
-- Laboratory Tests
-- Sonogram or Ultrasound
-- X-Rays
-- Mammogram
-- MRI or CAT Scan
-- EKG or ECG
-- EEG
-- Vaccination
-- Anesthesia
* DIAGNOSTIC OR PREVENTATIVE
-- General Exam, Checkup or Consultation
-- Cleaning, Prophylaxis, or Polishing
-- X-Rays, Radiographs, or Bitewings
-- Fluoride Treatment
-- Sealant (Plastic Coatings on Back Teeth)
* RESTORATIVE OR ENDODONTIC
-- Fillings
-- Inlays
-- Crowns or Caps
-- Root Canal
* PERIODONTIC (GUM TREATMENT)
-- Periodontal Scaling, Root Planing, or Gum Surgery
-- Periodontal Recall Visit (Periodic or Regular)
* ORAL SURGERY
-- Extraction, Tooth Pulled
-- Implants
-- Abscess or Infection Treatment
-- Other Oral Surgery
* PROSTHETICS
-- Fixed Bridges
-- Dentures or Removable Partial Dentures
-- Relining or Repair of Bridges or Dentures
* ORTHODONTICS
-- Orthodontia, Braces, or Retainers
* ADDITIONAL PROCEDURES
-- Bonding, Whitening, or Bleaching
-- Treatment for TMD or TMJ
-- Certified Nursing Assistant (CNA)
-- Companion
-- Dietitian/Nutritionist
-- Home Health/Home Care Aide
-- Hospice Worker
-- Homemaker
-- I.V. or Infusion Therapist
-- Medical Doctor
-- Nurse/Nurse Practitioner
-- Nurse’s Aide
-- Occupational Therapist
-- Personal Care Attendant
-- Physical Therapist
-- Respiratory Therapist
-- Social Worker
-- Speech Therapist
Medical Treatments
Changing bandages, wound care, giving medication, taking blood pressure, giving shots or injections, any type of therapy, other medical treatments
Help Using Medical Equipment or Assistive Device
(Examples)
Oxygen tank, wheelchair, walker, hospital bed, tub seat, special railing, special commode, other medical equipment or assistive device
Help With Daily Activities or Personal Care
(Examples)
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
Help With Daily
Activities or Personal Care
(Examples)
Using the telephone, paying bills, shopping, driving, housework, preparing meals, bathing, dressing, using the toilet, getting in or out of a bed or chair, walking, eating, other daily activities or personal care
-- Paid At Time Of Visit
-- Made A Copayment
-- Bill Sent Directly To Other Source
-- Bill Has Not Arrived
-- No Bill Sent:
-- HMO Plan
-- VA
-- Military Facility
-- Welfare/Medicaid
-- Worker’s Compensation
-- School, Employer, or Other Private Health Center/Clinic
-- Public Clinic/Health Center or Private Charity (Include Community and Migrant Health Center, Federally Qualified Health Center, Indian Health Services)
-- No Charge: Telephone Call
-- Free From Provider (Professional Courtesy/Free Sample)
-- Government-Financed Research And Clinical Trials
-- A Motor Vehicle
-- A Gun
-- Weapon Other Than a Gun
-- A Poison or Something That Can Poison (Like Gasoline or a Cleaning Fluid or Chemical)
-- A Fire or Something Hot That Would Cause a Burn
-- A Drowning or Near-Drowning
-- A Sports Injury
-- A Fall (Exclude Falls Related to Sports)
TYPES OF OVER-THE-COUNTER MEDICATION
-- Digestive System Problem Medication
Examples: antacids, laxatives, adult pain relievers, and diarrhea remedies
-- Respiratory Problem Medication
Examples: allergy/hay fever remedies, adult and children pain relievers, room vaporizers, liquid cold remedies, cough remedies, chest rubs/ointments, sprays/inhalers, cough drops, sore throat lozenges/gum, anesthetic throat lozenges, asthma remedies, nose drops, and special sinus remedies
-- Pain Problem Medication
Examples: adult and children pain relievers and pain relieving rubs
-- Skin Problem Medication
Examples: jock itch remedy, hemorrhoid remedies, anti-itch cream/lotion, diaper rash remedies, medicated powder/talc, antiseptics, suntan lotion, sunburn remedies, acne cream/lotion, athlete's foot remedies, dandruff shampoos, wart removers, psoriasis remedies, skin spot remedies, ingrown toenail remedies, and skin cream/lotion
-- Eye/Ear/Mouth Problem Medication
Examples: eye drops, eye washes, ear drops, lip products, mouth or gum pain reliever, cold sore remedies, dental floss products, sensitive teeth remedies, dental rinse, and adult and children pain relievers
-- Feminine Problem Medication
Examples: adult pain relievers, pre-menstrual/menstrual relief products, vaginal itching and irritation creams, feminine douches, and water pills
-- General Well-Being Problem Medication
Examples: adult pain relievers, diet pills, sleep aids, stay awake products, and motion sickness remedies
Financial/Insurance Problems
-- Couldn’t afford care
-- Insurance company wouldn’t approve, cover, or pay for care
-- Pre-existing condition
-- Insurance required a referral, but couldn’t get one
-- Doctor refused to accept family’s insurance plan
Transportation Problems
-- Medical care was too far away
-- Can’t drive or don’t have car/No public transportation available
-- Too expensive to get there
Communication Problems
-- Hearing impairment or loss
-- Different language
Physical Problems
-- Hard to get into building
-- Hard to get around inside building
-- No appropriate equipment in office
Other Problems
-- Couldn’t get time off work
-- Didn’t know where to go to get care
-- Was refused services
-- Couldn’t get child care
-- Didn’t have time or took too long
-- Hospital and Physician Benefits, Including Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
State-Specific Names of Medicare HMOs
(One for Each State)
State-Specific Plan Names
(One for Each State)
-- AFDC (Aid to Families with Dependent Children)
-- SSI (Supplemental Security Income)
-- WIC (Women, Infants, and Children)
-- IHS (Indian Health Service)
-- Public Health Clinic
-- VA (Veterans Administration)
-- From a Professional Association
-- From a Small Business Group
-- From a Union
-- From a Health Insurance Purchasing Alliance
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Previous Employer
-- From a Previous Employer (COBRA)
Sample Medicare Card
|
MEDICARE |
|
HEALTH INSURANCE | |
|
SOCIAL SECURITY ACT |
|||
| NAME OF BENEFICIARY | |||
| JOHN D. DOE | |||
| MEDICARE CLAIM NUMBER | SEX | ||
| 123-45-6789A | MALE | ||
| IS ENTITLED TO | EFFECTIVE DATE 1/1/95 | ||
|
HOSPITAL INSURANCE (PART A) |
|||
| MEDICAL INSURANCE (PART B) | |||
| SIGN HERE --> |
|
||
Sample State-Specific Medicaid Card
(One for Each State)
-- From a Group or Association
-- From a Health Insurance Purchasing Alliance
-- Directly Through a School
-- Directly From an Insurance Agent
-- Directly From Insurance Company
-- Directly From an HMO
-- From a Union
-- From Anyone’s Previous Employer (COBRA)
-- From Anyone’s Previous Employer (Not COBRA)
-- From Spouse’s/Deceased Spouse’s Previous Employer
-- From Some Other Employer
-- Under Plan of Someone Not Living Here
State-Specific Names of Medicare HMOs
(One for Each State)
State-Specific Plan Names
(One for Each State)
-- Hospital and Physician Benefits, Including Coverage Through an HMO
-- Dental
-- Prescription Drugs
-- Vision
-- Medicare Supplement or Medigap
-- Long-Term Care in a Nursing Home
-- Extra Cash for Hospital Stays
-- Serious Disease or Dread Disease
STATE-SPECIFIC PLAN NAMES OF FEDERAL INSURANCE PLANS
(FOR FEDERAL CIVILIAN EMPLOYEES)
(ONE FOR EACH STATE)
-- Cancer
-- Hypertension
-- Diabetes
-- Coronary Artery Disease
-- Some Other Condition
-- Very Satisfied
-- Somewhat Satisfied
-- Not Too Satisfied
-- Not At All Satisfied
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