Questionnaire Text

Questionnaire form view entire document:  text  image
16. Is this person currently covered by any of the following types of health insurance or health coverage plans?
Mark "Yes" or "No" for each type of coverage in items a - h.

a) Insurance through a current or former employer or union (of this person or another family member)
[] Yes
[] No
b) Insurance purchased directly from an insurance company (by this person or another family member)
[] Yes
[] No
c) Medicare, for people 65 and older, or people with certain disabilities
[] Yes
[] No
d) Medicaid, Medical Assistance, or any kind of government- assistance plan for those with low incomes or a disability
[] Yes
[] No
e) TRICARE or other military health care
[] Yes
[] No
f) VA (including those who have ever used or enrolled for VA health care)
[] Yes
[] No
g) Indian Health Service
[] Yes
[] No
h) Any other type of health insurance or health coverage plan -
[] Yes, specify ________
[] No
Questionnaire instructions view entire document:  text  image
Answer person questions 7 through 17 for all persons on pages 2, 3, and 4.

Questions 7-48 are a continuation of the questions for each person. (Questions 1-6 appear on pages 2, 3, and 4 of the questionnaire.)

18a-18c. Mark the "Yes" or "No" box to indicate if the person has serious difficulty with any of the activities listed in parts a, b, and c because of a physical, mental, or emotional condition.