Form CMS-10203 Medicare Health Outcomes Survey (HOS 3.0)

Medicare Health Outcomes Survey (HOS)
Questionnaire (English)

HOS 3.0 2015

1-2

Insert Cover Art (English)

Medicare Health Outcomes Survey Instructions
This survey asks about you and your health. Answer each question, thinking about yourself.
Please take the time to complete this survey. Your answers are very important to us. If you
are unable to complete this survey, a family member or “proxy” can fill out the survey about
you.
Please return the survey with your answers in the enclosed postage-paid envelope.
Sample Questions:
 Answer the questions by putting an ‘X’ in the box next to the appropriate answer like this:
57. Are you male or female?
1
2

Male
Female

 Be sure to read all the answer choices given before marking a box with an ‘X.’
 You are sometimes told to answer some questions in this survey only when you have answered
a previous question. When this happens, you will see an italicized instruction like the one below:
If you answered "yes" to question 34 above (that you have had cancer),
All information that would permit identification of any person who completes
this survey is protected by the Privacy Act and the Health Insurance Portability
and Accountability Act (HIPAA). This information will be used only for purposes
permitted by law and will not be disclosed or released for any other reason. If
you have any questions or want to know more about the study, please call
[vendor name] at [toll-free number].

“According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information that does not display a valid OMB control
number. The valid OMB control number for this information collection is 09380701. The time required to complete this information collection is estimated to
average 20 minutes including the time to review instructions, search existing
data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: CMS,
7500 Security Boulevard, C1-25-05, Baltimore, Maryland 21244-1850.”

OMB 0938-0701 Version 02-1
© 2015 by the National Committee for Quality Assurance (NCQA). This survey instrument may not be reproduced or transmitted in
any form, electronic or mechanical, without the express written permission of NCQA. All rights reserved.
Items 1–9: The VR-12 Health Survey item content was developed and modified from a 36-item health survey.

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Medicare Health Outcomes Survey
1.

In general, would you say your health is:
Excellent
1

2.

Very good

Good

2

Fair

3

4

Yes,
limited
a lot

No, not
limited
at all

1

2

3

b. Climbing several flights of stairs ...................................

1

2

3

During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of your physical health?
Yes,
a little
of the
time

Yes,
some
of the
time

Yes,
most
of the
time

Yes,
all of
the
time

a. Accomplished less than you would like .....

1

2

3

4

5

b. Were limited in the kind of work or other
activities .......................................................

1

2

3

4

5

During the past 4 weeks, have you had any of the following problems with your work or other
regular daily activities as a result of any emotional problems (such as feeling depressed or
anxious)?
No,
none
of the
time

5.

Yes,
limited
a little

a. Moderate activities, such as moving a table, pushing
a vacuum cleaner, bowling, or playing golf ....................

No,
none
of the
time

4.

5

The following items are about activities you might do during a typical day. Does your health
now limit you in these activities? If so, how much?

ACTIVITIES

3.

Poor

Yes,
a little
of the
time

Yes,
some
of the
time

Yes,
most
of the
time

Yes,
all of
the
time

a. Accomplished less than you would like .....

1

2

3

4

5

b. Didn't do work or other activities as
carefully as usual ........................................

1

2

3

4

5

During the past 4 weeks, how much did pain interfere with your normal work (including both
work outside the home and housework)?
Not at all
1

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A little bit
2

Moderately
3

Quite a bit
4

Extremely
5

These questions are about how you feel and how things have been with you during the past 4
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling.
6.

How much of the time during the past 4 weeks:
All
of the
time

7.

Most
of the
time

A good
bit of
the time

Some
of the
time

A little
of the
time

None
of the
time

a. Have you felt calm and
peaceful?.....................................

1

2

3

4

5

6

b. Did you have a lot of energy? ......

1

2

3

4

5

6

c. Have you felt downhearted
and blue? ....................................

1

2

3

4

5

6

During the past 4 weeks, how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting with friends, relatives, etc.)?
All of
the time
1

Most of
the time
2

Some of
the time
3

A little of
the time

None of
the time

4

5

Now, we’d like to ask you some questions about how your health may have changed.
8.

Compared to one year ago, how would you rate your physical health in general now?
Much better
1

9.

Slightly better
2

About the
same
3

Slightly worse
4

Much worse
5

Compared to one year ago, how would you rate your emotional problems (such as feeling
anxious, depressed or irritable) in general now?
Much better
1

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Slightly better
2

About the
same
3

Slightly worse
4

Much worse
5

Earlier in the survey you were asked to indicate whether you have any limitations in your activities.
We are now going to ask a few additional questions in this area.
10. Because of a health or physical problem, do you have any difficulty doing the following
activities without special equipment or help from another person?
No, I do not
have difficulty

Yes, I have
difficulty

I am unable to
do this activity

a. Bathing...............................................

1

2

3

b. Dressing .............................................

1

2

3

c. Eating.................................................

1

2

3

d. Getting in or out of chairs ...................

1

2

3

e. Walking ..............................................

1

2

3

f. Using the toilet ...................................

1

2

3

11. Because of a health or physical problem, do you have any difficulty doing the following
activities?
No, I do not
have difficulty
a. Preparing meals .................................
b. Managing money................................
c. Taking medication as prescribed ........

Yes, I have
difficulty

I don’t do this
activity

1

2

3

1

2

3

1

2

3

These next questions ask about your physical and mental health during the past 30 days.
12. Now, thinking about your physical health, which includes physical illness and injury, for how
many days during the past 30 days was your physical health not good?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.
days

13. Now, thinking about your mental health, which includes stress, depression, and problems with
emotions, for how many days during the past 30 days was your mental health not good?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.

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days

14. During the past 30 days, for about how many days did poor physical or mental health keep
you from doing your usual activities, such as self-care, work, or recreation?
Please enter a number between "0" and "30" days. If no days, please enter “0” days. Your best
estimate is fine.
days

Now we are going to ask some questions about specific medical conditions.
Yes
15. Are you blind or do you have serious difficulty seeing, even when
wearing glasses? ........................................................................................
16. Are you deaf or do you have serious difficulty hearing, even with a
hearing aid? ................................................................................................

No

1

2

1

2

17. Because of a physical, mental, or emotional condition, do you have
serious difficulty concentrating, remembering or making decisions? ..........

1

2

18. Because of a physical, mental, or emotional condition, do you have
difficulty doing errands alone such as visiting a doctor’s office or
shopping? ...................................................................................................

1

2

19. In the past month, how often did memory problems interfere with your daily activities?

Every day
(7 days a week)
1

Most days
(5-6 days a
week)
2

Some days
(2-4 days a
week)
3

Rarely
(once a week or
less)
4

Never
5

Has a doctor ever told you that you had:

Yes

20. Hypertension or high blood pressure ..........................................................

1

2

21. Angina pectoris or coronary artery disease ................................................

1

2

22. Congestive heart failure .............................................................................

1

2

23. A myocardial infarction or heart attack........................................................

1

2

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No

Has a doctor ever told you that you had:

Yes

No

24. Other heart conditions, such as problems with heart valves or the rhythm
of your heartbeat .........................................................................................

1

2

25. A stroke.......................................................................................................

1

2

26. Emphysema, or asthma, or COPD (chronic obstructive pulmonary
disease) ......................................................................................................

1

2

27. Crohn’s disease, ulcerative colitis, or inflammatory bowel
disease .......................................................................................................

1

2

28. Arthritis of the hip or knee ...........................................................................

1

2

29. Arthritis of the hand or wrist.........................................................................

1

2

30. Osteoporosis, sometimes called thin or brittle bones...................................

1

2

31. Sciatica (pain or numbness that travels down your leg to below your
knee)...........................................................................................................

1

2

32. Diabetes, high blood sugar, or sugar in the urine ........................................

1

2

33. Depression ..................................................................................................

1

2

34. Any cancer (other than skin cancer) ............................................................

1

2

If you answered "yes" to question 34 above (that you have had cancer),
Yes

35. Are you currently under treatment for:

No

a. Colon or rectal cancer ..........................................................................

1

2

b. Lung cancer .........................................................................................

1

2

c. Breast cancer.......................................................................................

1

2

d. Prostate cancer ....................................................................................

1

2

e. Other cancer (other than skin cancer) ..................................................

1

2

36. In the past 7 days, how much did pain interfere with your day to day activities?
Not at all
1

A little bit
2

Somewhat
3

Quite a bit
4

Very much
5

37. In the past 7 days, how often did pain keep you from socializing with others?
Never
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Rarely

Sometimes

Often

Always

1

2

3

4

38. In the past 7 days, how would you rate your pain on average?
No
pain
1
2
3
4
5
6
7
8
9
01

02

03

04

05

06

07

08

09

5

Worst imaginable
pain
10
10

39. Over the past 2 weeks, how often have you been bothered by any of the following problems?

Not at all
a. Little interest or pleasure in
doing things ..........................
b. Feeling down, depressed or
hopeless ...............................

Several
days

More than
half the
days

Nearly
every day

1

2

3

4

1

2

3

4

40. In general, compared to other people your age, would you say that your health is:
1
2
3
4
5

Excellent
Very good
Good
Fair
Poor

41. Do you now smoke every day, some days, or not at all?
1
2
3
4

Every day
Some days
Not at all
Don’t know

42. Many people experience leakage of urine, also called urinary incontinence. In the past six
months, have you experienced leaking of urine?
1
2

Yes

Go to Question 43

No

Go to Question 46

43. During the past six months, how much did leaking of urine make you change your daily
activities or interfere with your sleep?
1
2

A lot
Somewhat

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3

Not at all

44. Have you ever talked with a doctor, nurse, or other health care provider about leaking of urine?
1
2

Yes
No

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45. There are many ways to control or manage the leaking of urine, including bladder training
exercises, medication and surgery. Have you ever talked with a doctor, nurse, or other health
care provider about any of these approaches?
1
2

Yes
No

46. In the past 12 months, did you talk with a doctor or other health provider about your level of
exercise or physical activity? For example, a doctor or other health provider may ask if you
exercise regularly or take part in physical exercise.
1
2
3

Yes

Go to Question 47

No

Go to Question 47

I had no visits in the past 12 months

Go to Question 48

47. In the past 12 months, did a doctor or other health provider advise you to start, increase or
maintain your level of exercise or physical activity? For example, in order to improve your
health, your doctor or other health provider may advise you to start taking the stairs, increase
walking from 10 to 20 minutes every day or to maintain your current exercise program.
1
2

Yes
No

48. A fall is when your body goes to the ground without being pushed. In the past 12 months, did
you talk with your doctor or other health provider about falling or problems with balance or
walking?
1
2
3

Yes
No
I had no visits in the past 12 months

49. Did you fall in the past 12 months?
1
2

Yes
No

50. In the past 12 months, have you had a problem with balance or walking?
1
2

Yes
No

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51. Has your doctor or other health provider done anything to help prevent falls or treat problems
with balance or walking? Some things they might do include:
•
•
•
•
1
2
3

Suggest that you use a cane or walker.
Check your blood pressure lying or standing.
Suggest that you do an exercise or physical therapy program.
Suggest a vision or hearing testing.
Yes
No
I had no visits in the past 12 months

52. Have you ever had a bone density test to check for osteoporosis, sometimes thought of as
“brittle bones”? This test may have been done to your back, hip, wrist, heel or finger.
1
2

Yes
No

53. During the past month, on average, how many hours of actual sleep did you get at night? (This
may be different from the number of hours you spent in bed.)
Less than 5 hours
1
2
3
4

5 – 6 hours
7 – 8 hours
9 or more hours

54. During the past month, how would you rate your overall sleep quality?
Very Good
1
2
3
4

Fairly Good
Fairly Bad
Very Bad

55. How much do you weigh in pounds (lbs.)?

lbs.

56. How tall are you without shoes on in feet (ft.) and inches (in.)? Please remember to fill in both
feet and inches (for example, 5 ft. 00 in.) If 1/2 in., please round up.

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ft.

in.

57. Are you male or female?
1
2

Male
Female

58. Are you Hispanic, Latino/a or Spanish Origin? (One or more categories may be selected)
1
2
3
4
5

No, not of Hispanic, Latino/a or Spanish origin
Yes, Mexican, Mexican American, Chicano/a
Yes, Puerto Rican
Yes, Cuban
Yes, Another Hispanic, Latino/a or Spanish origin

59. What is your race? (One or more categories may be selected)
White
Korean
01
08
02
03
04
05
06
07

Black or African American
American Indian or Alaska Native
Asian Indian
Chinese
Filipino
Japanese

60. How well do you speak English?
1
2
3
4

Very well
Well
Not well
Not at all

61. What is your current marital status?

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09
10
11
12
13
14

Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander

1
2
3
4
5

Married
Divorced
Separated
Widowed
Never married

62. What is the highest grade or level of school that you have completed?
1
2
3
4
5
6

8th grade or less
Some high school, but did not graduate
High school graduate or GED
Some college or 2 year degree
4 year college graduate
More than a 4 year college degree

63. Do you live alone or with others? (One or more categories may be selected)
1
2
3
4
5

Alone
With spouse/significant other
With children/other relatives
With non-relatives
With paid caregiver

64. Where do you live?
1
2
3
4

House, apartment, condominium or mobile home Go to Question 65
Assisted living or board and care home
Nursing home

Go to Question 66

Other

Go to Question 66

Go to Question 65

65. Is the house or apartment you currently live in:
1
2
3
4
5

Owned or being bought by you
Owned or being bought by someone in your family other than you
Rented for money
Not owned and one in which you live without payment of rent
None of the above

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66. Who completed this survey form?
1
2
3
4

Person to whom survey was addressed

Go to Question 68

Family member or relative of person to whom the survey was addressed
Friend of person to whom the survey was addressed
Professional caregiver of person to whom the survey was addressed

67. If you completed the survey for someone else, please fill in your name. DO NOT complete this
question if you completed the survey for yourself. Please print clearly.
First Name
Last Name

68. Which of the following categories best represents the combined income for all family
members in your household for the past 12 months?
Less than $5,000
01
02
03
04
05
06
07
08
09
10

$5,000–$9,999
$10,000–$19,999
$20,000–$29,999
$30,000–$39,999
$40,000–$49,999
$50,000–$79,999
$80,000–$99,999
$100,000 or more
Don’t know
YOU HAVE COMPLETED THE SURVEY. THANK YOU.

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Insert Vendor Contact Information Here

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