CMS-10861 HOS Field Test Item Differences by Questionnaire

Attachment C. HOS Field Test Item Differences by Questionnaire Version

Field Test Questionnaire Version A			Field Test Questionnaire Version B
2. Does your health now limit you in these activities? If so, how much? a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf Yes, limited a lot Yes, limited a little No, not limited at all			2. Does your health now limit you in these activities? If so, how much? a. Moderate activities, such as moving a table, pushing a vacuum cleaner, or walking at a brisk pace Yes, limited a lot Yes, limited a little No, not limited at all
6. How much of the time during the past 4 weeks: a. Have you felt calm and peaceful? All of the time Most of the time A good bit of the time Some of the time A little of the time			6. How much of the time during the past 4 weeks: a. Have you felt calm and peaceful? All of the time Most of the time Some of the time A little of the time None of the time
6		None of the time
b. Did you have a lot of energy? 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			b. Did you have a lot of energy? All of the time Most of the time Some of the time A little of the time None of the time
c. Have you felt downhearted and sad? 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			c. Have you felt downhearted and sad? All of the time Most of the time Some of the time A little of the time None of the time
Field Test Questionnaire Version A			Field Test Questionnaire Version B
8. Because of a health or physical problem, do you have any difficulty doing the following activities without special equipment or help from another person?			8. Because of a health or physical problem, do you have any difficulty doing the following activities without help from another person?
12. Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? 5 Not at all 4 Very little 3 Somewhat 2 Quite a lot 1 Cannot do			12. Does your health now limit you in doing moderate activities, such as moving a table, pushing a vacuum cleaner, or walking at a brisk pace? 5 Not at all 4 Very little 3 Somewhat 2 Quite a lot 1 Cannot do
38. In the past 12 months, has a doctor or other health professional talked with you about your diet or eating habits? Yes No I had no visits in the past 12 months			38. In the past 12 months, has a doctor or other health professional provided advise about your diet or eating habits? Yes No I had no visits in the past 12 months
39. In the past 12 months, has a doctor or other health professional talked with you about your alcohol use? Yes No I had no visits in the past 12 months			39. In the past 12 months, has a doctor or other health professional provided advice about your alcohol use? Yes No I had no visits in the past 12 months