Survey Text

2021 2014 2007 2000
2020 2013 2006 1999
2019 2012 2005 1998
2018 2011 2004 1997
2017 2010 2003 1996
2016 2009 2002
2015 2008 2001
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2021

No questionnaire text is available for this sample.


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2020

No questionnaire text is available for this sample.


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2019

No questionnaire text is available for this sample.


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2018
Survey form view entire document:  text  image
ER50 (ER1025)
BLAISE NAME: CodeAllERSvc
Context Header: 
[PERSON?S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EVN-DT]
Question Text:
And ER-2.
Looking at this card, which of these services, if any, did [you/[PERSON]] have during this visit?
ENTER ALL THAT APPLY.
HELP: F1
Responses: 
LABORATORY TESTS 1 ER60 (ER1035)
SONOGRAM OR ULTRASOUND 2 ER60 (ER1035)
X-RAYS 3 ER60 (ER1035)
MAMMOGRAM 4 ER60 (ER1035)
MRI OR CATSCAN 5 ER60 (ER1035)
EKG, ECG, OR EEG 6 ER60 (ER1035)
VACCINATION 7 ER60 (ER1035)
NONE OF THESE SERVICES RECEIVED 95 ER60 (ER1035)
REFUSED RF ER60 (ER1035)
DON'T KNOW DK ER60 (ER1035)
Programmer Instructions: 
Soft Check:
If coded ?4? (MAMMOGRAM) and person being asked about is male or is female and less than or = 17 years of age (or age categories 1-3), display the following message: ?UNLIKELY RESPONSE FOR [MALES/CHILDREN 17 AND YOUNGER]. VERIFY AND RE-ENTER.?
Display ?MALE? in error message if person being asked about is a male greater than 17 years of age (or age categories 4 through 9). Display ?CHILDREN 17 AND YOUNGER? in the error message if person being asked about is male or female and less than or = 17 years of age (or age categories 1-3).
Allow code '95' (NONE OF THESE SERVICES RECEIVED) , 'RF' (REFUSED), and 'DK' (DON'T KNOW) alone only; these responses may not be selected with any other response.
Note: 'NONE OF THESE SERVICES RECEIVED' is not displayed on show card.
Hard check:
Edit: if coded ?95? (NONE OF THESE SERVICES RECEIVED), no other service categories can be coded.
If interviewer selects another code with NONE OF THESE SERVICES RECEIVED, display the following message: "NONE OF THESE SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER OPTIONS. VERIFY AND RE- ENTER."
Display Instructions:
MV90 (MV1070)
BLAISE NAME: MVSvcTp
Context Header: 
(PERSON?S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE
PROVIDER) - (DOC OR DEPT (EVN-DT)
Question Text:
MV-2.
Looking at card MV-2, which of these services, if any, did (you/(PERSON)) have during this visit?
ENTER ALL THAT APPLY.
HELP: F1
Responses: 
LABORATORY TESTS 1 MV100 (MV1075)
SONOGRAM OR ULTRASOUND 2 MV110 (MV1080)
X-RAYS 3 MV110 (MV1080)
MAMMOGRAM 4 MV110 (MV1080)
MRI OR CATSCAN 5 MV110 (MV1080)
EKG, ECG, OR EEG 6 MV110 (MV1080)
VACCINATION 7 MV110 (MV1080)
NONE OF THESE SERVICES RECEIVED 95 MV110 (MV1080)
REFUSED RF MV110 (MV1080)
DON'T KNOW DK MV110 (MV1080)
Programmer Instructions: 
Soft check:
If MV90 (MVSvcTp) is coded '4' (MAMMOGRAM) and person being asked about is male or is female and less than or equal to 17 years of age (or age categories 1-3), display the following message: "UNLIKELY RESPONSE FOR (MALES/CHILDREN 17 AND YOUNGER). VERIFY AND RE-ENTER."
Display 'MALES' in error message if person being asked about is a male greater than 17 years of age (or age categories 4 through 9). Display 'CHILDREN 17 AND YOUNGER' in the error message if person being asked about is male or female and less than or equal to 17 years of age (or age categories 1-3).
Allow code '95' (NONE OF THESE SERVICES RECEIVED), 'RF' (REFUSED) and 'DK' (DON'T KNOW) alone only. These responses may not be selected with any other response.
'NONE OF THESE SERVICES RECEIVED' is not displayed on show card.
Hard check:
Edit: If MV90 (MVSvcTp) is coded '95' (NONE OF THESE SERVICES RECEIVED), no other treatment categories can be coded. If interviewer selects another code with 'NONE OF THESE SERVICES', display the following message: "NONE OF THESE SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER OPTIONS. VERIFY AND RE-ENTER."
Display Instructions:
OP80 (OP1060)
BLAISE NAME: CodeAllOPSvc
Context Header: 
(PERSON?S FIRST MIDDLE AND LAST NAME) (NAME OF MEDICAL CARE PROVIDER)-(DOC OR DEPT) (EVN-DT)
Question Text:
OP-2.
Looking at card OP-2, which of these services, if any, did (you/ (PERSON)) have during this visit?
ENTER ALL THAT APPLY
HELP: F1
Responses: 
LABORATORY TESTS 1 OP90 (OP1070)
SONOGRAM OR ULTRASOUND 2 OP90 (OP1070)
X-RAYS 3 OP90 (OP1070)
MAMMOGRAM 4 OP90 (OP1070)
MRI OR CATSCAN 5 OP90 (OP1070)
EKG, ECG, OR EEG 6 OP90 (OP1070)
VACCINATION 7 OP90 (OP1070)
NONE OF THESE SERVICES RECEIVED 95 OP90 (OP1070)
REFUSED RF OP90 (OP1070)
DON'T KNOW DK OP90 (OP1070)
Programmer Instructions: 
Soft check:
If OP80 (CodeAllOPSvc) is coded '4' (MAMMOGRAM) and person being asked about is male or is female and less than or equal to 17 years of age (or age categories 1-3), display the following message: "UNLIKELY RESPONSE FOR (MALE/CHILDREN 17 AND YOUNGER). VERIFY AND RE-ENTER."
Display 'MALES' in error message if person being asked about is a male greater than 17 years of age (or age categories 4 through 9). Display 'CHILDREN 17 AND YOUNGER' in the error message if person being asked about is male or female and less than or equal to 17 years of age (or age categories 1-3).
Allow OP80 (CodeAllOPSvc) code '95' (NONE OF THESE SERVICES RECEIVED), 'RF' (REFUSED), and 'DK' (DON'T KNOW) alone only. These responses may not be selected with any other response.
'NONE OF THESE SERVICES RECEIVED' is not displayed on show card.
Hard check:
Edit: If OP80 (CodeAllOPSvc) is coded ?95? (NONE OF THESE SERVICES RECEIVED), no other treatment categories can be coded. If interviewer selects another code with 'NONE OF THESE SERVICES', display the following message: "NONE OF THESE SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER OPTIONS. VERIFY AND RE- ENTER."
Display Instructions:

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2017
Survey form view entire document:  text  image
ER05
====

[PERSON?S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did [you/[PERSON]] have during this visit?
CHECK ALL THAT APPLY.
LABORATORY TESTS ....................... 1 [ER06]
SONOGRAM OR ULTRASOUND ................. 2 [ER06]
X-RAYS ................................. 3 [ER06]
MAMMOGRAM .............................. 4 [ER06]
MRI OR CATSCAN ......................... 5 [ER06]
EKG OR ECG ............................. 6 [ER06]
EEG .................................... 7 [ER06]
VACCINATION ............................ 8 [ER06]
ANESTHESIA ............................. 9 [ER06]
OTHER DIAGNOSTIC TEST ................. 10 [ER06]
THROAT SWAB ........................... 11 [ER06]
NO SERVICES RECEIVED .................. 95 [ER06]
REF ................................... -7 [ER06]
DK .................................... -8 [ER06]
HELP AVAILABLE FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE ?4? (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS GREATER THAN 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE ?95? (NO SERVICES RECEIVED), ?-7? (REFUSED), AND ?-8? (DON?T KNOW) ALONE ONLY; THESE RESPONSES MAY NOT BE SELECTED WITH ANY OTHER RESPONSE.
----------------------------------------------------
----------------------------------------------------
NOTE: ?OTHER DIAGNOSTIC TESTS? AND ?NO SERVICES RECEIVED? ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
----------------------------------------------------
HARD CHECK:
EDIT: IF CODED ?95? (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES CAN BE CODED. IF INTERVIEWER SELECTS ANOTHER CODE WITH ?NO SERVICES?, DISPLAY THE FOLLOWING MESSAGE: ?NO SERVICES RECEIVED CANNOT BE SELECTED WITH OTHER OPTIONS. VERIFY AND RE-ENTER.?
----------------------------------------------------
----------------------------------------------------
NOTE: CODE ?11? (THROAT SWAB) IS DISPLAYED ON THE SCREEN AND ON THE SHOW CARD BETWEEN CODES ?1? (LABORATORY TESTS) AND ?2? (SONOGRAM OR ULTRASOUND).
----------------------------------------------------

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2016
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2015
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2014
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
1999
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
1998
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
ER05
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER....] [EVN-DT]
SHOW CARD ER-2.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
[Code All That Apply]
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST ENTRY FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER. CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'XRAY'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
----------------------------------------------------
----------------------------------------------------
NOTE: 'OTHER DIAGNOSTIC TESTS' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------
OP11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER......] [EVN-DT]
SHOW CARD OP-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
----------------------------------------------------
ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
----------------------------------------------------
----------------------------------------------------
ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
----------------------------------------------------
----------------------------------------------------
EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
----------------------------------------------------
----------------------------------------------------
WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
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NOTE: 'OTHER DIAGNOSTIC TEST' AND 'NO SERVICES RECEIVED' ARE NOT DISPLAYED ON SHOW CARD.
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MV11
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE
PROVIDER......] [EVN-DT]
SHOW CARD MV-3.
Looking at this card, which of these services, if any, did (PERSON) have during this visit?
CODE '95' IF NO SERVICES WERE RECEIVED.
CODE ALL THAT APPLY.
LABORATORY TESTS ....................... 1
SONOGRAM OR ULTRASOUND ................. 2
X-RAYS ................................. 3
MAMMOGRAM .............................. 4
MRI OR CATSCAN ......................... 5
EKG OR ECG ............................. 6
EEG .................................... 7
VACCINATION ............................ 8
ANESTHESIA ............................. 9
OTHER DIAGNOSTIC TEST ................. 10
NO SERVICES RECEIVED .................. 95
REF ................................... -7
DK .................................... -8
[Code All That Apply]
PRESS F1 FOR DEFINITIONS OF ANSWER CATEGORIES.
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ALLOW CODE '4' (MAMMOGRAM) ONLY IF PERSON IS FEMALE AND AGE IS ) 17 YEARS (OR AGE CATEGORIES 4 THROUGH 9).
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ALLOW CODE '95' (NO SERVICES RECEIVED), '-7' (REFUSED), AND '-8' (DON'T KNOW) AS ENTRIES IN THE FIRST FIELD ONLY. ALL OTHER RESPONSE CODES MAY BE ENTERED IN ANY ENTRY FIELD, IN ANY ORDER.
CODE '95' WILL NOT APPEAR AS A RESPONSE CATEGORY ON THE SCREEN.
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EDIT: IF CODED '95' (NO SERVICES RECEIVED), NO OTHER SERVICE CATEGORIES SHOULD BE CODED. IF A SECOND CODE IS ENTERED, DISPLAY THE FOLLOWING MESSAGE: 'INVALID RESPONSE. PRESS ENTER ON A BLANK FIELD.'
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WHEN AN ANSWER CATEGORY IS ENTERED IN AN ENTRY FIELD, CAPI WILL DISPLAY AN ANSWER CATEGORY ABBREVIATION BELOW THE ENTRY FIELD. THE FOLLOWING ANSWER CATEGORY ABBREVIATIONS SHOULD BE USED FOR THIS DISPLAY:

CODE '1' = 'LAB'
CODE '2' = 'ULTRA'
CODE '3' = 'X-RAYS'
CODE '4' = 'MAMMO'
CODE '5' = 'MRI'
CODE '6' = 'EKG'
CODE '7' = 'EEG'
CODE '8' = 'VACIN'
CODE '9' = 'ANEST'
CODE '10'= 'OTHER'
CODE '95'= 'NONE'
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NOTE: 'NO SERVICES RECEIVED' IS NOT DISPLAYED ON SHOW CARD.
----------------------------------------------------