[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

5. In the last 12 months (not counting times you went to an emergency room), how many times did you go to a doctor's office or clinic to get care for yourself?

None ..........................................GO TOQUESTION 11
1 ..............................................................
2 ..............................................................
3 ..............................................................
4 ..............................................................
5 to 9 .........................................
10 or more ..................................

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-3.
In the last 12 months, how often did (PERSON)'s doctors or other health providers show respect for what you had to say?

NEVER .................................. 1
SOMETIMES .............................. 2
USUALLY ................................ 3
ALWAYS ................................. 4
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-3.
In the last 12 months, how often did (PERSON)'s doctors or other health providers show respect for what you had to say?

NEVER .................................. 1
SOMETIMES .............................. 2
USUALLY ................................ 3
ALWAYS ................................. 4
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]

6. In the last 12 months, did you or a doctor believe you needed any care, tests, or treatment?

A big problem
A small problem
Not a problem

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, did you or a doctor believe (PERSON) needed any care, tests, or treatment?

YES .................................... 1
NO ..................................... 2 [CS15]
REF ................................... -7 [CS15]
DK .................................... -8 [CS15]