Survey Text

2017 2011 2005 1999
2016 2010 2004 1998
2015 2009 2003 1997
2014 2008 2002 1996
2013 2007 2001
2012 2006 2000
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2017
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE ASK: Did [you/[PERSON]] obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since [START DATE]?
GLASSES OR CONTACT LENSES .............. 1 [BOX_06]
INSULIN ................................ 2 [BOX_06]
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3 [BOX_06]
[Code All That Apply]
----------------------------------------------------
IF CODED ?2? (INSULIN), ADD ?INSULIN? TO PERSON?S-PRESCRIBED-MEDICINES-ROSTER, CREATING NECESSARY RECORDS FOR INSULIN.
----------------------------------------------------
----------------------------------------------------
IF CODED ?3? (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD ?OTHER DIABETIC EQUIP/SUPPLIES? TO PERSON?S-PRESCRIBED-MEDICINES-ROSTER, CREATING NECESSARY RECORDS FOR ?OTHER DIABETIC EQUIP/SUPPLIES?.
----------------------------------------------------

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2016
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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2015
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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2014
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2013
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2012
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2011
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2010
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2009
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2008
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2007
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2006
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2005
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2004
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2003
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2002
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2001
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
2000
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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1999
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

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1998
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1997
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------

top
1996
Survey form view entire document:  text  image
EV03
====

[PERSON'S FIRST MIDDLE AND LAST NAME] [EV] [STR-DT] [END-DT]
IF KNOWN, SELECT CORRECT OME ITEM GROUP.
OTHERWISE, ASK: Did (PERSON) obtain glasses or contact lenses, insulin, or other diabetic equipment or supplies since (START DATE)?
GLASSES OR CONTACT LENSES .............. 1
INSULIN ................................ 2
OTHER DIABETIC EQUIPMENT OR SUPPLIES ... 3
[Code All That Apply]
----------------------------------------------------
IF CODED '2' (INSULIN), ADD 'INSULIN' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
IF CODED '3' (OTHER DIABETIC EQUIPMENT OR SUPPLIES), ADD 'OTHER DIABETIC EQUIP/SUPPLIES' TO PERSON'S-PRESCRIBED-MEDICINES-ROSTER.
----------------------------------------------------
----------------------------------------------------
GO TO BOX_06
----------------------------------------------------