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11H-000
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May I continue? |
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11H-001
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I will read out the names of a series of illnesses. Have you been newly diagnosed with or advised to seek medical advice for any of those illnesses since the time of the last interview? |
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11H-001-1
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Heart disease (angina, heart failure, cardiac infarction, heart valve disease, etc.) |
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11H-001-2
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High blood pressure |
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11H-001-3
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Hyperlipidemia |
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11H-001-4
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Cerebral stroke, cerebrovascular accident |
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11H-001-5
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Diabetes |
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11H-001-6
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Chronic lung disease (chronic bronchitis, emphysema, etc.; excluding lung cancer) |
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11H-001-7
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Asthma |
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11H-001-8
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Liver disease (hepatitis B or C, hepatic cirrhosis, etc.; excluding liver cancer) |
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11H-001-9
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Ulcer or other |
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11H-001-10
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Joint disorder (arthritis, rheumatism) |
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11H-001-11
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Femoral neck fracture |
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11H-001-12
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Osteoporosis |
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11H-001-13
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Eye disease (cataracts, glaucoma, etc.) |
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11H-001-14
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Ear disorder (hearing loss, etc.) |
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11H-001-15
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Bladder disorder (incontinence, difficulty in urinating, enlarged prostate) |
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11H-001-16
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Parkinson’s disease |
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11H-001-17
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Depression, emotional disorder |
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11H-001-18
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Dementia |
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11H-001-19
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Skin disorder |
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11H-001-20
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Cancer or other malignant tumor (including leukemia, lymphoma; excluding benign skin cancer) |
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11H-001-21
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Other (Specify the most serious one: __________) |
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11H-001-1-2
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If the answer to 11H-001-1 is 1, 2, or 3, go to 11H-001-1-3; if 4, go to 11H-001-2-2. |
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11H-001-1-3
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Are you regularly taking any medicine prescribed by your doctor for your heart disease? |
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11H-001-2-2
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If the answer to 11H-001-2 is 1, 2, or 3, go to 11H-001-2-3; if 4, go to 11H-001-3-2. |
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11H-001-2-3
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Are you regularly taking any medicine prescribed by your doctor for your high blood pressure? |
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11H-001-3-2
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If the answer to 11H-001-3 is 1, 2, or 3, go to 11H-001-3-3; if 4, go to 11H-001-4-2. |
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11H-001-3-3
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Are you regularly taking any medicine prescribed by your doctor for your hyperlipidemia? |
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11H-001-4-2
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If the answer to 11H-001-4 is 1, 2, or 3, go to 11H-001-4-3; if 4, go to 11H-001-5-2. |
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11H-001-4-3
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Are you regularly taking any medicine prescribed by your doctor for your cerebral stroke and/or cerebrovascular accidents? |
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11H-001-5-2
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If the answer to 11H-001-5 is 1, 2, or 3, go to 11H-001-5-3; if 4, go to 11H-001-20-2. |
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11H-001-5-3
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What treatment are you on for your diabetes? Please select all that apply. |
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11H-001-20-2
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If the answer to 11H-001-20 is 1, 2, or 3, go to 11H-001-20-3; if 4, go to 11H-001-22. |
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11H-001-20-3
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Where is/are your cancer(s) or malignant tumor(s) located? Please select 1 or 0 for each respective organ of the part of the body listed below to indicate the presence or absence of any malignant tumor. |
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11H-001-22
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If the respondent is female, go to 11H-002; if male, go to 11H-003. |
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11H-002
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In the past two years, did you have a mammogram? |
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11H-003
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In the past two years, did you have your stool tested for the presence of blood as a way to screen for colon cancer? |
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11H-004
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In the past 12-month period, did you have any physical examination, excluding those performed as part of treatment at a hospital? |
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11H-004-1
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Which of the following examinations did you take? Select all that apply. |
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11H-004-2
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How much did you pay for your health examinations? If there was no payment, please say so. |
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11H-004-3
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Why did you not have any physical examinations? Please select all that apply. |
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11H-005
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Which of the following types of health insurance do you have? If you are not sure, please check your insurance card. |
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11H-006
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Are you the primary insured or a dependent? |
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11H-007
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Did you or any of your family members postpone doctor visits during the past 12-month period despite being in need of treatment? |
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11H-007-2
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Why did you or your family member(s) postpone doctor visits? Please select all that apply. |
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11H-008
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If the respondent is age 65 or above, go to 11H-009; otherwise, go to 11H-010. |
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11H-009
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Are you entitled to and taking advantage of subsidies (partial exemption from co-payments) under the medical expense assistance program for the low-income elderly (age 65 and above)? |
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11H-010
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Have you ever been certified as requiring assistance or care under the public Long-term Care Insurance Program? |
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11H-010-2
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Are you participating in any such program? |
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11H-011
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If the answer to 11H-005 is 4 or 5, or if the answer to 11H-010 is 1, go to 11H-012; if the answer to 11H-005 is 7, go to 11H-012b; otherwise, go to 11H-013. |
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11H-012
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Would you permit us to see the records? |
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11H-012b
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We have been told that we would be given access to the records if we obtain your signed approval. Would you permit us to see the records? |
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11H-012-2a
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Thank you. Could I ask you to provide us with your health and long-term care insurance card numbers? |
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11H-012-2b
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Thank you. Could I ask you to provide us with your health and long-term care insurance card numbers? |
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11H-013
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In the past 12-month period, did you visit a doctor, acupuncturist, or bonesetter? |
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11H-014
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Are you making regular monthly visits to any hospital, medical or acupuncture clinic, or bonesetting studio? |
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11H-014-1-1
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How often do you go there? Please answer in terms of the number of times per week, month, or year. |
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11H-014-1-2
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How much did you pay for medical expenses and/or treatment on average per visit, including any amount paid for prescription drugs? If there was no payment, please say so. |
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11H-014-2-1
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In this and the next question, please answer about the facility which you visit most frequently. How often do you go there? |
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11H-014-2-2
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How much did you pay for medical expenses and/or treatment on average per visit, including any amount paid for prescription drugs? If there was no payment, please say so. |
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11H-014-2-3
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How much did you pay on average per month for medical expenses and/or treatment at all of these facilities? |
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11H-015
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Was the outpatient treatment covered by your insurance or was it outside of the coverage? |
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11H-016
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In the past 12-month period, did you go to a dentist or a dental hygienist? |
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11H-017
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In the past 12-month period, how many times in total did you see a dentist or dental hygienist? |
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11H-018
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How much did you pay in total for the treatment during the past 12-month period? |
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11H-019
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Was the dental treatment you received during the past 12-month period covered by your insurance or was it outside of the coverage? |
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11H-020
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Have you been hospitalized overnight or longer during the past 12-month period? |
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11H-021
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How many times have you been hospitalized overnight or longer during the past 12-month period? |
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11H-022
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How many night(s) did you spend in the hospital in total during the past 12-month period? |
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11H-023
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How much did you pay in total for hospitalization during the past 12-month period? If there was no payment, please say so. |
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11H-024
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Was the cost of the hospitalization covered by your insurance or was it outside of the coverage? |
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11H-025
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What percentage of medical costs are you required to pay out of pocket for services covered by public health insurance? |
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11H-026
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I would like to ask you about your situation with respect to the public Long-term Care Insurance Program. When were you first certified as requiring assistance or care under the program? |
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11H-027
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For which level of assistance or care were you certified at the time? |
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11H-028
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For which level of assistance or care are you currently certified? |
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11H-029
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For assistance and care services under the Long-term Care Insurance Program, how much did you pay out of pocket per month over the past 12-month period? If there was none, please say so. |
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11H-030
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In the past 12-month period, did you receive any assistance or care service at home or as a visitor at facilities? |
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11H-030-1
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Physical care |
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11H-030-2
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Housekeeping assistance |
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11H-030-3
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Home visit for bathing assistance |
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11H-030-4
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Nurse visit |
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11H-030-5
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Home rehabilitation |
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11H-030-6
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Rehabilitation at facilities (Day stay service) |
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11H-030-7
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Rehabilitation at care facilities (Day care service) |
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11H-030-8
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Short-term stay at care facilities |
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11H-030-9
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Did not use any of the above services |
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11H-030-10
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Don’t know |
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11H-030-11
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Refused to answer |
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11H-031
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Were you or have you been institutionalized in any care facility for any length of time during the past 12-month period? |
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11H-032
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In which of the following facilities were you or have you been institutionalized? If you don’t know what type, could you tell me the name of the facility? |
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11H-033
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How long did you stay in total? |
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11H-034
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In the past 12-month period, how much did you spend per month on the purchase of care services and goods, other than those covered by your long-term care insurance? |
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11H-035
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In the past 12-month period, did you provide personal care to your family members, relatives, friends, or neighbors, or help them with such tasks as housekeeping and filling out documents? |
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11H-036
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Let me ask more specifically. Did you provide personal care involving physical contact, such as helping change clothes, bathing, eating, and going to the bathroom? |
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11H-036-1
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To whom did you provide such personal care? |
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11H-036-2
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Among the person(s) you cited in the previous question, to whom did you provide care most frequently? |
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11H-036-3
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Over the past 12-month period, how often did you provide such care? Please select the one that best describes your answer. |
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11H-036b
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During the past 12-month period, did you help anyone with household tasks, such as cooking, doing laundry, changing light bulbs, moving furniture, shopping, and tending the garden? |
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11H-036b-1
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Who did you help with such household tasks? |
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11H-036b-3
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Over the past 12-month period, how often did you provide such help? Please select the one that best describes your answer. |
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11H-037
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During the past 12-month period, did you receive personal care from your family members, relatives, friends, or neighbors, or were you helped by any of such persons with non-personal tasks such as housekeeping and filling out documents? |
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11H-038
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Did you receive personal care involving physical contact, such as help with changing clothes, bathing, eating, and going to the bathroom? |
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11H-038-1
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From whom did you receive such personal care? Please identify each person in terms of his/her relationship to you. |
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11H-038-2
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Among the person(s) you cited in the previous question, who provided you with such personal care most frequently? |
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11H-038-3
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Over the past 12-month period, how often did you receive such personal care? Please select the one that best describes your answer. |
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11H-039
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During the past 12-month period, did you receive help with household tasks, such as cooking, doing laundry, changing light bulbs, moving furniture, shopping, and tending the garden? |
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11H-039-1
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Who helped you with such household tasks? Please identify each person in terms of his/her relationship to you. |
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11H-039-2
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Among the person(s) you cited in the previous question, who helped you most frequently with household tasks? |
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11H-039-3
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Over the past 12-month period, how often did you receive help with household tasks? |
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11H-040
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Interviewer read-out: This concludes this section. Thank you for your cooperation.] |
