CMS-10203 Medicare Health Outcomes Survey-Modified (HOS-M)

Medicare Health Outcomes Survey—
Modified (HOS-M)
Questionnaire (English)
2015
Insert HOS-M Cover Art (English)

Medicare Health Outcomes Survey Modified Instructions
This survey asks about your health, feelings, and ability to do daily activities. Please take the
time to complete this survey. Your answers are very important to us. If you need help to
complete this survey, a family member or a friend may fill out the survey about your health.
If a family member or a friend is NOT available, please ask your nurse or other health
professional to help.
Sample Questions:
Answer the questions by putting an ‘X’ in the box next to the appropriate answer category like this:
1
2

Yes
No

 Be sure to read all the answer choices given before marking a box with an ‘X.’
 You may find some of the questions to be personal. It is important that you answer EVERY
question on this survey. However, you do not have to answer a question if you do not want to. If
you are unsure of the answer to a question or that the question applies to you, just choose the
BEST available answer.
 Please complete the survey within two weeks and return it in the enclosed postage-paid
envelope.
IF YOU ARE FILLING OUT THIS SURVEY FOR SOMEONE ELSE
Please answer every question the way you believe best describes that person’s health,
feelings, and ability to do daily activities. Answer each question the way you think the
person you are helping would answer about him or herself.
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 0938-0701. 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, 6–13: The VR-12 Health Survey item content was developed and modified from a 36-item health
survey.

Medicare Health Outcomes Survey—Modified
1.

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

2.

1

2

Fair

3

Poor

4

5

A little difficulty

Some
difficulty

2

3

A lot of difficulty

Not able to
do it

4

5

How much difficulty, if any, do you have walking a quarter of a mile—that is about 2 or 3
blocks?
No difficulty
at all
1

4.

Good

How much difficulty, if any, do you have lifting or carrying objects as heavy as 10 pounds, such
as a sack of potatoes?
No difficulty
at all

3.

Very good

A little difficulty

Some
difficulty

2

3

A lot of difficulty

Not able to
do it

4

5

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

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5.

Do you receive help from another person with any of these activities?
Yes, I receive
help

6.

I do not 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

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?
Yes,
limited
a lot

ACTIVITIES

7.

No, I do not
receive help

Yes,
limited
a little

No, not
limited
at all

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

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? (If you are not able to do work or
regular daily activities, please answer ‘yes, all of the time’ to both questions).
No,
none of
the time

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

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8.

During the past 4 weeks, have you had any of the following problems with your regular daily
activities as a result of any emotional problems (such as feeling depressed or anxious)? (If
you are not able to do work or regular daily activities, please answer ‘yes, all of the time’ to
both questions.)
No,
none of
the time

9.

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

A little bit

Moderately

2

Quite a bit

3

Extremely

4

5

These questions are about how you feel and how things have been with you during the past four
weeks. For each question, please give the one answer that comes closest to the way you have
been feeling.
10. How much of the time during the past 4 weeks:
All
of the
time

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

11. 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

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Most of
the time
2

Some of
the time
3

A little of
the time
4

None of
the time
5

Now, we’d like to ask you some questions about how your health may have changed.
12. Compared to one year ago, how would you rate your physical health in general now?
Much better

Slightly better

1

2

About the
same

Slightly worse

3

Much worse

4

5

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

Slightly better

1

2

About the
same

Slightly worse

3

Much worse

4

5

14. Do you experience memory loss that interferes with daily activities?
1

2

Yes
No

15. How often, if ever, do you have difficulty controlling urination (bladder accidents)?
Never

Less than once
a week

1

2

Once a week or
more often
3

Daily
4

Catheter
5

16. Who completed this survey form?
1

2

3

Medicare Participant

STOP HERE

Family member, relative, or friend of Medicare Participant

Go to Question 17

Nurse or other health professional

Go to Question 17

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17. What was the reason you filled out this survey for someone else? (Please answer ALL that
apply.)
1

2

3

4

5

Physical problems
Memory loss or mental problems
Unable to speak or read English
Person not available
Other

18. How did you help complete this survey? (Please answer ALL that apply.)
1

2

3

4

5

6

Read the questions to the person
Wrote down the person’s answers
Answered the questions based on my experience with the person
Used medical records to fill out the survey
Translated the survey questions
Other

FOR PROFESSIONAL STAFF (CAREGIVERS) ONLY
19. Which of the following best describes your position? (Please choose one answer.)
1

2

3

4

5

6

Home Health Aide, Personal Care Attendant, or Certified Nursing Assistant
Nurse (RN, LPN, or NP)
Social Worker or Case Manager
Adult Foster Care/Adult Day Care/Assisted Living/Residential Care Staff
Interpreter
Other
YOU HAVE COMPLETED THE SURVEY. THANK YOU.

OMB 0938-0701

Insert Vendor Contact Information Here

OMB 0938-0701