Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

None, Skip to Question 12
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

Disagree Strongly
Disagree Somewhat
Uncertain
Agree Somewhat
Agree Strongly

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

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

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

3. In the last 12 months, not counting the times you needed care right away, did you make any appointments for your health care at a doctor?s office or clinic?

1 Yes
2 No
Skip to Question 5

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
SHOW CARD CS-3A.
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic to get health care?

NONE ................................... 0 [CS20]
1 TIME ................................. 1 [CS14A]
2 TIMES ................................ 2 [CS14A]
3 TIMES ................................ 3 [CS14A]
4 TIMES ................................ 4 [CS14A]
5 TO 9 TIMES............................ 5 [CS14A]
10 OR MORE TIMES ....................... 6 [CS14A]
REF ................................... -7 [CS20]
DK .................................... -8 [CS20]
[Code One]
----------------------------------------------------
IN PANEL 12, ROUND 4 AND PANEL 13, ROUND 2, THE QUESTION WORDING AT CS13 WAS UPDATED TO BE MORE CONSISTENT WITH CAHPS VERSION 4.0 QUESTION WORDING.
----------------------------------------------------

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

0 None
Skip to Question 13
1 1
2 2
3 3
4 4
5 5 to 9
6 10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

0 None: Skip to Question 13
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

None Skip to Question 13
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

None ? Skip to Question 13
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

None, Skip to Question 12
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

None, Skip to Question 12
1
2
3
4
5 to 9
10 or more

[PERSON'S FIRST MIDDLE AND LAST NAME]
In the last 12 months, not counting times (PERSON) went to an emergency room, how many times did (PERSON) go to a doctor's office or clinic?

NONE ................................... 0 [CS20]
1 TIME ................................. 1
2 TIMES ................................ 2
3 TIMES ................................ 3
4 TIMES ................................ 4
5 TO 9 TIMES ........................... 5
10 OR MORE TIMES ....................... 6
REF ................................... -7
DK .................................... -8
[Code One]

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

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

In the last 12 months (not counting times your child
went to an emergency room), how many times did
your child go to a doctor's office or clinic?

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