CMS-P-0015A MCBS Facility Round 46 Health Status Base Line

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA. HEALTH STATUS
(BASELINE ONLY)

HA. HEALTH STATUS
(BASELINE ONLY)

BOX HA1

If this is the first time for this respondent in Section HA, go to HA1PRE1.
Else, go to HA1PRE2.

RECORD IDENTIFICATION
HA1PRE1
The next questions are about {SP}'s health status on or around {REF DATE}. We have found that much of the data
we are collecting is usually located in the resident's {full Minimum Data Set (MDS) assessments, the Quarterly
Review forms, and other medical chart notes/medical record}. Please take a moment to locate the records now and
confirm they are the records closest to {REF DATE}.
PRESS ENTER TO CONTINUE.
HA1PRE2
{Those are all of the questions we have about {SP}'s health on {BASELINE REF DATE}. Now, I would like to ask
some questions about {his/her} health at {T2 REF DATE}./The following questions are about {SP}'s health status on
or around {REF DATE}.
Current Stay Roster
PLACE NAME
{ }
{ }
{ }
etc.

START DATE
{ }
{ }
{ }

END DATE
{ }
{ }
{ }

PLACE TYPE
{ }
{ }
{ }

USE ARROW KEYS. TO EXIT, PRESS ESC.

BOX HA2

If Baseline, go to HA1,
If Time 2, and
If Baseline and Time 2 done in same facility this round, and
If at Baseline, SP had a full MDS or Quarterly Review (HA2=1 (YES)), go to HA2B,
Else, go to HA9PRE.
If Baseline done in previous round in this facility, and
If SP had a full MDS or Quarterly Review (HA2=1 (YES)), go to HA2B;
Else, go to HA1
If Core Supplement,
If at last HS application administered for this SP, SP had a full MDS or QR (HA2 or
HA2B=1 (YES), go to HA2B. Else, go to HA1.

HA1
Do you have {SP's} medical records for the {admission} period on or around {REF DATE}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX HA2A)
(HA1A)
(HA1A)
(HA9PRE)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA1A
Is there someone else I should speak with, or do the records exist elsewhere?
PRESS ENTER TO CONTINUE.
HA1B
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT THE
MEDICAL RECORDS?
YES, CONTINUE WITHOUT MEDICAL RECORDS....................
NO, RETURN TO NAVIGATE SCREEN
(RECORD NEW RESPONDENT/RECORDS ON FROG) ........

BOX
HA2A

1

(HA9PRE)

0

(RETURN TO
NAVIGATE SCREEN)

If facility is a nursing home PLACE TYPE = NURSING HOME or a rehabilitation facility
(PLACTYPE = 17), go to HA2.
Else, go to HA9PRE.

HA2
Do the medical records contain any full MDS assessment {or Quarterly Review} Forms?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(BOX HA3)
(HA2A)
(HA2A)
(HA9PRE)

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA2A
Is there someone else I should speak with, or do the records exist elsewhere?
PRESS ENTER TO CONTINUE.
HA2B1
DO YOU WANT TO CONTINUE THE INTERVIEW FOR THIS SP WITH THIS RESPONDENT WITHOUT ANY MDS
FORMS?
YES, CONTINUE WITHOUT MDS ..............................................
NO, RETURN TO NAVIGATE SCREEN
(RECORD NEW RESPONDENT/RECORDS ON FROG) ........

BOX HA3

If Baseline, FCF, or FFC, go to HA3A. Else, go to HA2B.

2

1

(HA9PRE)

0

(RETURN TO
NAVIGATE SCREEN)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA2B
Do {SP}'s medical records contain {another/a full} MDS assessment or Quarterly Review form dated {after/on or
around}
{{Time
2
REF
DATE}/{BCVAD}/{DATE
OF
BASELINE
INTERVIEW}/{CORE
REF
DATE}/{CCVAD}/{TCVAD}}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

1
0
-8
-7

(HA3B)
(HA2C)
(HA2C)
(HA9PRE)

1

(HA9PRE)

0

(RETURN TO
NAVIGATE SCREEN)

HA2C
Is there someone else I should speak with or do the records exist elsewhere?
CONTINUE WITH THIS RESPONDENT AND THIS SP..............
RETURN TO NAVIGATE SCREEN TO BEGIN ANOTHER
SP OR TO RETRIEVE RECORDS ............................................
(RECORD NEW RESPONDENT/RECORDS ON FROG)

{LAST ASSESSMENT DATE COLLECTED: {ASSESSMENT DATE}}
HA3A
{What is the assessment date on the full MDS assessment that was completed for {SP} {at admission, that is,} on or
around {REF DATE}}. {What is the assessment date on that form}?
{IF NO MDS AVAILABLE AROUND {REF DATE}}, ENTER SHIFT/5 IN MONTH.}
MONTH (

) DAY (

) YEAR (

)

(BOX HA4)

HA3B
What is the assessment date on the full MDS assessment or Quarterly Review that was completed closest to {REF
DATE} for {SP} after {{FAD+14/RAD+14}/{BCVAD}/{CORE REF DATE}/{CCVAD}/{TIME 2 REF
DATE}/{TCVAD}/{BASELINE REF DATE}/{BCVAD}}.
{IF NO MDS OR QUARTERLY REVIEW AVAILABLE, ENTER SHIFT/5 IN MONTH.}
MONTH (

BOX HA4

) DAY (

) YEAR (

)

If SHIFT/5 entered in month, and
If first time at HA3A/HA3B, go to HA9PRE;
Else, go to BOX HA5.

3

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

Determine if last date in HA3A/HA3B is valid by applying the following criteria. Date is
valid if it falls on or between the dates below:
Baseline: SSM1
SSM2/CFC
Time 2:
Core:
If CFR:
If LAST HS is BL
If LAST HS is T2:
If TCVADYR = REFYR
Else
If LAST HS is Core:
If CCVADYR = REFYR
Else

BOX HA5

5\1\{SAMPYR} to 2\31\{SAMPYR}/DOI/DOD
FAD to FAD+14/DOI/DOD
BCVAD+1/FAD+14 to FAD+150/DOI/DOD
BCVAD+1/FAD+15 to 12/31/{YR}/DOI/DOD
TCVAD+1/FAD+120 to 12/31/{YR}/DOI/DOD
5/1/{YR} to 12/31/{YR}/DOI/DOD
CCVAD+1/FAD+120 to 12/31/{YR}/DOI/DOD
5/1/{YR} to 12/31/{YR}/DOI/DOD

If FFC or
FCF

RAD to RAD+14/DOI/DOD

And,
If year is not missing, and
If month is not missing, and
If date is valid, set a flag and go to Box HA6.
If date is invalid, go to HA5.

BOX HA6

Obtain state name from Facility's address. If state name is MS or SD, set HA4=1 and
go to HA5. Else, go to HA4.

HA4
Please tell me if the form with the assessment date of {LAST ASSESSMENT DATE ENTRY IN HA3A/HA3B}
contains the following section:
D. VISION
YES (FULL MDS).........................................................................
NO (QUARTERLY REVIEW) .......................................................
DK ................................................................................................
RF ................................................................................................

4

1
0
-8
-7

HA. HEALTH STATUS

BOX HA7

2006 Facility Interview
(Baseline Only)

Compare most recent Assessment Date with REF DATE. If number of days between
Assessment Date and REF DATE > 7, or if day only in HA3A or HA3B is DK or
RF, continue.
Else, go to BOX HA9.

HA5
Besides the form you just told me about, does {SP's} medical record contain any other MDS form {or Quarterly
Review form} dated closer to {REF DATE}?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

BOX HA8

1
0
-8
-7

If another form is available (HA5 = 1 (YES)),
If Baseline or if FCF go to HA3A.
If Time 2 or Core, go to HA3B.
Else, go to BOX HA9.

1.
2.
3.
4.

BOX HA9
5.
6.

If one assessment date in HA3A/HA3B and FORM TYPE is Full MDS and
assessment date is valid, set a flag to indicate this is the BCVAD/TCVAD/CCVAD
and go to HA6.
If only one assessment date in HA3A/HA3B and FORM TYPE is Quarterly Review
and assessment date is valid, set a flag to indicate this date is the
BCVAD/TCVAD/CCVAD and go to HA7A.
If no assessment dates are valid or one form and form type is unknown, treat as
having no MDS or Quarterly Review and go to HA9PRE.
If more than 1 valid assessment date (2 or more flags set to valid in BOX HA5), go
to step 4a. to determine which assessment date is the BCVAD/TCVAD/CCVAD.
4a. If all dates have valid entries in the DAY, MONTH and YEAR fields and form
type is known, select the date which is closest to REF DATE as the
BCVAD/TCVAD/CCVAD.
4b. If at least one of the dates does not have valid entries in DAY or MONTH or
form type is unknown, consider only the dates and form types with complete
information in determining BCVAD/TCVAD/CCVAD.
4c. If two dates are equally close to REF DATE, select the date before REF
DATE as the BCVAD/TCVAD/CCVAD.
If Form Type in HA4 for BCVAD/TCVAD/CCVAD identified in step 4 is a full MDS
assessment, go to HA6. If Quarterly Review, go to step 6.
Review HA3A/HA3B and Box HA5; if any of the valid dates are for a full MDS form
(HA4 = Full MDS), select the full MDS as the Backup MDS and go to HA7C. If
more than one full MDS with a valid date, select the date closest to the REF DATE
as the Backup MDS and go to HA7C.
Else (no valid dates in HA3A/HA3B), go to step 7.
7. If no additional dates collected in HA3A/HA3B, go to HA7A.
8. If only one additional date in HA3A/HA3B and it is an MDS, go to BOX HA10.
9. If HA3A/HA3B contains more than one full MDS assessment date, determine
which assessment date is the closest to the REF DATE. If two or more dates
are equally close to REF DATE, select the full MDS form dated before REF
DATE, then go to BOX HA10.

5

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA6
What was the primary reason for the assessment on the full MDS assessment dated {BCVAD/TCVAD}?
ADMISSION ................................................................................ 1
ANNUAL ..................................................................................... 2
SIGNIFICANT CHANGE IN STATUS .......................................... 3
OTHER (SPECIFY:_____________________) .......................... 91
DK ............................................................................................... -8
RF ............................................................................................... -7

6

(HA7C)
(HA7C)
(HA7C)
(HA7C)
(HA7C)
(HA7C)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA7A
Does {SP}'s medical record contain a full MDS assessment dated between {DATE RANGE}.
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(GO TO HA7B)
(GO TO HA7C)
(GO TO HA7C)
(GO TO HA7C)

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA7B
What is the date of the full MDS assessment closest to {REF DATE}?
IF NO MDS AVAILABLE, ENTER SHIFT/5 IN MONTH. (HA7C)
MONTH (

) DAY (

) YEAR (

)

Determine if date in HA7B is valid by applying the following criteria. Date in range if it falls on
or between the dates below:
PATH/SP TYPE
RANGE
Baseline
SSM1
1\1\{SAMPYR} to 1\14\{SAMPYR+1}/DOI/DOD
SSM2

FAD-30 to FAD+30/DOI/DOD

CFC

FAD-30 to FAD+30/DOI/DOD

Time 2
BCVAD+1/FAD+14 to FAD+270/DOI/DOD
Core
If CFR:
If LAST HS is BL
If LAST HS is T2:
If TCVADYR = REFYR
Else
If LAST HR is Core:
If CCVADYR = REFYR
Else

BOX
HA10

BCVAD+1/FAD+15 to 12/31/{YR}/DOI/DOD
TCVAD+1/FAD+120 to 12/31/{YR}/DOI/DOD
5/1/{YR} to 12/31/{YR}/DOI/DOD
CCVAD+1/FAD+120 to 12/31/{YR}/DOI/DOD
5/1/{YR} to 12/31/{YR}/DOI/DOD

If FFC or
FCF

RAD to RAD+14/DOI/DOD

And,
If year is not missing, and
If month is not missing.
If date is valid, set a flag to indicate it is the backup MDS date.
Then, go to HA7C.

HA7C
Please refer to the {FORM TYPE} with the assessment date of {CLOSEST VALID ASSESSMENT DATE} when
answering the following questions. {If the information is not found on the Quarterly Review, {please refer to the full
MDS form with the assessment date of {BACK MDS ASSESSMENT DATE}/please refer to {SP}'s medical record} to
answer the questions.}

BOX HA11

If Baseline, continue. If Time 2, go to HA11. If Core, go to HA10.

7

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)
1.

If no MDS Form (HA2 = NO, DK, RF or -1), go to HA9.

2.

If IN1 and INSU.ICAIDNUM=-8 or -7; or
If IN1=-1, -8, or -7; or
If IN14A=0, -1, -8, or -7 and INSU.ICARENUM or INSU.ICARERRB=-1, -8, or -7;
Go to HA44PRE.
Else, go to Step 3.

3.

If education level (BQ9) = -1, DK or RF, go to BOX HA23.
Else, go to HA9.

BOX HA19

HA44PRE
This next section asks for {SP}'s {ID NUMBER TYPE} number(s) as recorded on the MDS assessment form.
PRESS ENTER TO CONTINUE.

BOX HA20

If SP's Medicare number is missing (IN14A not = 1 and IN15 = -1, DK or RF), go to
HA44A.
All others, go to BOX HA21.

HA44A
Please look at the MDS and find {SP}'s Medicare ID number. The Medicare ID number for {SP} that we show in our
records is {MEDICARE #/RRB #}. Is this the same ID number that you have in your records?
YES..............................................................................................
NO................................................................................................
SP HAS NO MEDICARE NUMBER ............................................
DK ................................................................................................
RF ................................................................................................

1
0
2
-8
-7

HA44AA
Does {SP}'s Medicare ID number begin with a letter or a number?
LETTER .......................................................................................
NUMBER .....................................................................................

8

1
2

(BOX HA21)

(BOX HA21)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

MEDICARE NUMBER
HA44B
Please read me {SP}'s Medicare ID number from the MDS assessment form.
MEDICARE: (

)-(
AREA

)-(
GROUP

)-(
END

RRB: (

)
BIC

)
RRB#

DK ...............................................................................................
RF ...............................................................................................

-8
-7

(BOX HA21)

HA45
I'd like to verify the Medicare ID number that I have recorded. I have entered {MEDICARE ID #/RRB #}. Is this
correct?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(BOX HA21)
(BOX HA21)

HA46
Let me enter it again. (What {is/was} {SP}'s Medicare ID number?)
)-(

MEDICARE: (
AREA
RRB: (

)-(
GROUP

)

)-(
END

)

(HA45)

BIC

(HA45)

RRB#
DK ..........................................................
RF ..........................................................

BOX HA21

If SP's Medicaid number is missing and not pending, go to HA47.
Else, go to Box HA23.

9

-8
-7

(BOX HA21)
(BOX HA21)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

MEDICAID NUMBER
HA47
Please read me {SP}'s {PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)}
ID number from the MDS assessment form.
IF NO MEDICAID NUMBER, CODE SHIFT/5. (BOX HA23)
_____________________________
MEDICAID ID NUMBER
DK ...............................................................................................
RF ...............................................................................................

-8
-7



(BOX HA23)

HA48
I'd like to verify the {PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME FOR MEDICAID)} ID
number that I have recorded. I have entered {MEDICAID NUMBER} . Is this correct?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................
RF ...............................................................................................

1
0
-8
-7

(BOX HA23)
(BOX HA23)
(BOX HA23)

HA49
Let me enter it again. (What {is/was} the {"PREFERRED" NAME FOR MEDICAID} {(or "ALLOWED FOR" NAME
FOR MEDICAID)} ID number?)
_____________________________
MEDICAID ID NUMBER

(HA48)

DK ...............................................................................................
RF ...............................................................................................

BOX HA23

-8
-7

(BOX HA23)
(BOX HA23)

If education level is missing (BQ9 = -1, DK or RF) and the MDS version flag = 2,
go to HA51. Else, go to HA9.

EDUCATION LEVEL
HA51
As far as you know, what {is/was} the highest level of schooling {SP} completed?
IF DK, USE CATEGORIES AS PROBES.
NO FORMAL SCHOOLING ........................................................
ELEMENTARY (1ST-8TH GRADES) ..........................................
SOME HIGH SCHOOL (9TH-12TH GRADES) ...........................
COMPLETED HIGH SCHOOL, NO COLLEGE...........................
TECHNICAL OR TRADE SCHOOL ............................................
SOME COLLEGE........................................................................
COLLEGE GRADUATE ..............................................................
GRADUATE DEGREE ...............................................................
DK ...............................................................................................
RF ...............................................................................................

10

1
2
3
4
5
6
7
8
-8
-7

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

MENTAL HEALTH (MR/DD)
HA9PRE
Now I have some questions concerning {SP}'s health on or around{REF DATE/{his/her} admission to the facility}.
{{Please refer to {SP}'s medical record/Since I will be collecting information about {SP} on or around {REF DATE}
and there is no MDS or Quarterly Review available close to that date, please refer to {SP's} medical record for the
information./Since you do not have a medical record at hand for reference, please think about the information found
in {SP}'s medical record} to answer these questions.}
PRESS ENTER TO CONTINUE.
HA9
Did {SP}'s record indicate any history of mental retardation, mental illness, or developmental disability problems?
Exclude diagnoses of organic brain syndrome, Alzheimer's disease, and related dementia.
MENTAL

NO .....................................................................................................
YES ...................................................................................................
DK ......................................................................................................
RF ......................................................................................................

0
1
-8
-7

ADVANCED DIRECTIVES
HA10
Now, please tell me which of the following advanced directives were listed in {SP}'s record or chart for the period on
or around {REF DATE}.
Did {SP}'s record indicate
{VARIABLE PART OF QUESTION}
ADLIVWIL
ADDNRES
ADDNHOSP
ADOTREST

LIVING WILL
DO NOT RESUSCITATE
DO NOT HOSPITALIZE
FEEDING/MEDICATION/OTHER TREATMENT RESTRICTION
NONE CHECKED
DON'T KNOW

11

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

COMATOSE
HA11
Was {SP} comatose on {REF DATE}?
COMATOSE

BOX HA12

NO (NOT COMATOSE) ..............................................................
YES (COMATOSE) ........................................................................
DK ..................................................................................................
RF ..................................................................................................

0
1
-8
-7

(HA12-13)
(HA12-13)
(HA12-13)

If Baseline or Core, go to HA28PRE.
If Time 2, go to HA39.

MEMORY/COGNITIVE SKILLS
HA12PRE
The next series of questions deal with {SP}'s memory or recall ability.
HA12
On or around {REF DATE}, was {SP}'s short-term memory okay, that is, did {she/he} seem or appear to recall
things after 5 minutes?
CSMEMST

MEMORY OK..............................................................................
MEMORY PROBLEM..................................................................

0
1

HA13
Was {SP}'s long-term memory okay; that is, did {she/he} seem or appear to recall events in the distant past?
CSMEMLT

MEMORY OK..............................................................................
MEMORY PROBLEM..................................................................

0
1

HA14
Was {SP} able to recall {VARIABLE PART OF QUESTION} on or around {REF DATE}?
CSCURSEA
CSLOCROM
CSNAMFAC
CSINNH

CURRENT SEASON
LOCATION OF OWN ROOM
STAFF NAMES/FACES
THAT SHE/HE IS IN NURSING HOME
NONE CHECKED
DON'T KNOW

12

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA15
How skilled was {SP} in making daily decisions? Was {she/he} independent, did {she/he} exhibit modified
independence, was {she/he} moderately impaired, or was {she/he} severely impaired?
CSDECIS

INDEPENDENT ..........................................................................
MODIFIED INDEPENDENCE .....................................................
MODERATELY IMPAIRED ..........................................................
SEVERELY IMPAIRED................................................................

0
1
2
3

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

BOX HA13

If Baseline or Core, go to HA16. If Time 2, go to HA21.

HEARING/COMMUNICATION
HA16
What was the condition of {SP}'s hearing, with a hearing appliance, if used, on or around {REF DATE}? Did {she/he}
hear adequately, did {she/he} have minimal difficulty, did {she/he} hear only in special situations, or was {her/his}
hearing highly impaired?
HCHECOND

HEARS ADEQUATELY................................................................
HEARS WITH MINIMAL DIFFICULTY .........................................
HEARS IN SPECIAL SITUATIONS ONLY...................................
HEARING HIGHLY IMPAIRED ....................................................

0
1
2
3

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA17
Did {she/he} have a hearing aid?
HCHEAID

YES.........................................................
NO ..........................................................

1
0

HA18PRE
The next section deals with how {SP} communicated with others and how well {she/he} was understood by
others.
PRESS ENTER TO CONTINUE.
HA18
Which statement best describes how effective {SP} was at making {herself/himself} understood on or around {REF
DATE}? Was {she/he} always understood, usually understood, sometimes understood, or rarely or never
understood?
HCUNCOND

UNDERSTOOD ......................................
USUALLY UNDERSTOOD .....................
SOMETIMES UNDERSTOOD ................
RARELY/NEVER UNDERSTOOD..........

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

13

0
1
2
3

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA19
Which statement best describes how well {SP} understood others on or around {REF DATE}? Did {SP} always
understand, usually understand, sometimes understand, or rarely or never understand?
HCUNDOTH

UNDERSTAND .......................................
USUALLY UNDERSTAND......................
SOMETIMES UNDERSTAND.................
RARELY/NEVER UNDERSTAND ..........

0
1
2
3

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

VISION
HA20PRE
Next is a question concerning {SP}'s vision on or around {REF DATE}.
PRESS ENTER TO CONTINUE.

HA20
Which of the following statements best described {SP}'s ability to see in adequate light with visual aids, if used?
Would you say {her/his} vision was adequate, impaired, moderately impaired, highly impaired, or severely impaired?
VISION

ADEQUATE ............................................
IMPAIRED...............................................
MODERATELY IMPAIRED .....................
HIGHLY IMPAIRED ................................
SEVERELY IMPAIRED...........................

0
1
2
3
4

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA20A
Does {SP} use a visual appliance such as glasses, contact lenses, or a magnifying glass?
VISAPPL

YES.........................................................
NO ..........................................................

14

1
0

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

BEHAVIORAL SYMPTOMS
HA21
How often did the following behavioral problems occur on or around {REF DATE}? Would you say
{VARIABLE PART OF QUESTION}
did not occur, occurred less than daily, or occurred daily or more frequently?
{CODE FROM {MDS/QR} COLUMN A.}

BSWANDER
BSVERBAB
BSPHYSAB
BSDISRPT
BSRESIST

A.
B.
C.
D.
E.

0. NOT AT ALL
1. LESS THAN DAILY
2. DAILY OR MORE FREQUENTLY

WANDERING .........................................................................
VERBALLY ABUSIVE BEHAVIOR .........................................
PHYSICALLY ABUSIVE BEHAVIOR .....................................
SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIOR ......
RESISTANCE TO CARE........................................................

(
(
(
(
(

)
)
)
)
)

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

BOX HA13A

If Baseline or Core, continue. If Time 2, go to HA22PRE.

PSYCHOSOCIAL WELL-BEING
HA27
The next question is about {SP}'s psychological and social well-being. Please tell me which of the following items
describe {her/him}.
On or around {REF DATE}, {SP}:
{VARIABLE PART OF QUESTION}?

{

SHOW
CARD
HA2

}

PWINTOTH
PWSTRACT
PWSLFACT
PWGOALS
PWFACLIF
PWGRPACT
PWNOFC

AT EASE INTERACTING WITH OTHERS
AT EASE DOING PLANNED OR STRUCTURED ACTIVITIES
AT EASE DOING SELF-INITIATED ACTIVITIES
ESTABLISHES OWN GOALS
PURSUES INVOLVEMENT IN LIFE OF FACILITY
ACCEPTS INVITATIONS INTO MOST GROUP ACTIVITIES
HAS ABSENCE OF PERSONAL CONTACT WITH FAMILY/FRIENDS
NONE OF THE ABOVE

ADLS/PHYSICAL FUNCTIONING
HA22PRE
The next questions are about {SP}'s ability to perform Activities of Daily Living or ADLs, on or around {REF DATE}.
I will read you a list of activities and would like you to tell me if {SP}'s self-performance was independent, required
supervision, required limited assistance, required extensive assistance, was totally dependent, or if the activity did
not occur. {By self-performance I mean what {SP} actually did for {himself/herself} and how much help was required
by staff members.}
PRESS ENTER TO CONTINUE.

15

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA22
Please tell me {SP}'s level of self-performance in
{VARIABLE PART OF QUESTION}

{

SHOW
CARD
HA1

}

CODE LEVEL OF SELF-PERFORMANCE
PFTRNSFR
PFLOCOMO
PFDRSSNG
PFEATING
PFTOILET

0. INDEPENDENT
3. EXTENSIVE ASSISTANCE

A. TRANSFER ...............................................
B. LOCOMOTION ON UNIT ..........................
C. DRESSING ...............................................
D. EATING .....................................................
E. TOILET USE .............................................
1. SUPERVISION
4. TOTAL DEPENDENCE

(
(
(
(
(

)
)
)
)
)

2. LIMITED ASSISTANCE
8. ACTIVITY DID NOT OCCUR

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA23
Again referring to the time on or around {REF DATE}, what was {SP}'s level of self-performance when bathing: was
{she/he} independent, did {she/he} require supervision, require physical help limited to transfer only, require physical
help in part of the bathing activity, was {she/he} totally dependent, or did the activity not occur?
PFBATHNG

INDEPENDENT ...........................................................................
SUPERVISION ............................................................................
PHYSICAL HELP LIMITED TO TRANSFER ONLY .....................
PHYSICAL HELP IN PART OF BATHING ACTIVITY..................
TOTAL DEPENDENCE................................................................
ACTIVITY DID NOT OCCUR .......................................................

0
1
2
3
4
8

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

MODES OF LOCOMOTION
HA24PRE
The next questions are about modes of locomotion and appliances or devices {SP} might have used around {REF
DATE}.
PRESS ENTER TO CONTINUE.

16

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA24
On or around {REF DATE},
{VARIABLE PART OF QUESTION}?
MLCANE
MLWHLSLF
MLWHLOTH
MLWHLPRIM

CANE/WALKER
WHEELED SELF
OTHER PERSON WHEELED
WHEELCHAIR PRIMARY MEANS
NONE CHECKED
DON'T KNOW

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

BOX HA14

If Baseline or Core, go to HA25PRE. If Time 2, go to HA39.

17

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

CONTINENCE
HA25PRE
The next questions are about {SP}'s bowel and bladder control on or around {REF DATE}.
PRESS ENTER TO CONTINUE.

HA25
What was the level of {SP}'s bowel control on or around {REF DATE}? Was {she/he} continent, usually continent,
occasionally incontinent, frequently incontinent, or incontinent?
CTBOWEC

CONTINENT ...............................................................................
USUALLY CONTINENT ..............................................................
OCCASIONALLY INCONTINENT................................................
FREQUENTLY INCONTINENT ..................................................
INCONTINENT ...........................................................................

0
1
2
3
4

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA26
What was the level of {SP}'s bladder control on or around {REF DATE}? Was {she/he} continent, usually continent,
occasionally incontinent, frequently incontinent, or incontinent?
CTBADDC

CONTINENT ...............................................................................
USUALLY CONTINENT ..............................................................
OCCASIONALLY INCONTINENT................................................
FREQUENTLY INCONTINENT ..................................................
INCONTINENT ...........................................................................

0
1
2
3
4

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

DIAGNOSES/CONDITIONS
HA28PRE
{MDS ASSESSMENT DATE:

{BCVAD}}

The questions in the next section deal with {SP}'s active diagnoses or conditions during the time on or around
{REF DATE} {By active I mean those disease associated with {her/his} ADL status, cognition, behavior, medical
treatments, or risk of death on or around {REF DATE}. Please think about what is in {SP}'s medical record
when answering the following questions.}
PRESS ENTER TO CONTINUE.

18

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA28
{MDS ASSESSMENT DATE: {BCVAD/CCVAD}}
{What active diseases were checked on {SP's} MDS assessment}? {Look at this list and tell me what active
diseases did {SP} have on or around {REF DATE}}?
SELECT ALL THAT APPLY.

{

SHOW
CARD
HA3

}

ALLERGY
ALZHMR
ANEMIA
ANXIETY
APHASIA
ASHD
ARTHRIT
ASTHMA
CANCER
CARDDYSR
CARDIOV
CATARCT
CERPALSY
STROKE
HRTFAIL
VEINTHR
DEMENT
DEPRESS
DIABMEL
DIABRET
EMPCOPD
GLAUCOMA
HEMIPLPA
HIPFRACT
HYPETENS
HYPETHYR
HYPOTENS
HYPOTHYR
MACDEGEN
MANICDEP
MISSLIMB
SCLEROS
OSTEOP
PARAPLEG
PARKNSON
BONEFRAC
VASCULAR
QUADPLEG
RENTFAIL
SCHIZOPH
SEIZURE
TIA
BRAININJ

Allergies
Alzheimer's Disease
Anemia
Anxiety Disorder
Aphasia
Arteriosclerotic Heart Disease (ASHD)
Arthritis
Asthma
Cancer
Cardiac Dysrhythmia
Cardiovascular Disease (other)
Cataracts
Cerebral Palsy
Cerebrovascular Accident (Stroke)
Congestive Heart Failure
Deep Vein Thrombosis
Dementia, Other Than Alzheimer's
Depression
Diabetes Mellitus
Diabetic Retinopathy
Emphysema/COPD
Glaucoma
Hemiplegia/Hemiparesis
Hip Fracture
Hypertension
Hyperthyroidism
Hypotension
Hypothyroidism
Macular Degeneration
Manic Depression (Bipolar Disease)
Missing Limb (e.g., amputation)
Multiple Sclerosis
Osteoporosis
Paraplegia
Parkinson's Disease
Pathological Bone Fracture
Peripheral Vascular Disease
Quadriplegia
Renal Failure
Schizophrenia
Seizure Disorder
Transient Ischemic Attack (TIA)
Traumatic Brain Injury
{Other {SPECIFY: __________________}}
None of the Above

19

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA29
{What active infections were checked on {SP}'s MDS assessment?}
{Look at the following list and tell me what active infection {SP} had on or around {REF DATE} according to the
medical record notes.}
SELECT ALL THAT APPLY.

{

SHOW
CARD
HA4

}

BOX HA15

INFMRSA
INFCDIFF
INFCONJ
INFHIV
INFPNEU
INFRESP
INFSEPT
INFSEXTR
INFTBRC
INFURNRY
INFHPPTS
INFWOUND

ANTIBIOTIC RESISTANT INFECTION (e.g., METHICILLIN RESISTANT STAPH)
CLOSTRIDIUM DIFFICILE (C.DIFF.)
CONJUNCTIVITIS
HIV INFECTION
PNEUMONIA
RESPIRATORY INFECTION
SEPTICEMIA
SEXUALLY TRANSMITTED DISEASES
TUBERCULOSIS
URINARY TRACT INFECTION IN LAST 30 DAYS
VIRAL HEPATITIS
WOUND INFECTION
NONE OF THE ABOVE

If HA3A/HA3B = BCVAD,/CCVAD, go to HA30.
Else go to BOX HA16.

HA30
MDS ASSESSMENT DATE: {BCVAD/CCVAD}
Were there any active diagnoses entered on the MDS form in the section for other diagnoses?
YES..............................................................................................
NO................................................................................................
DK ................................................................................................
RF ................................................................................................

20

1
0
-8
-7

}

(BOX HA16)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA31

SHOW
CARD
HA5

What were the diagnoses?
ENTER ICD-9 CODES WHEN DIAGNOSES TEXT IS MISSING OR ILLEGIBLE.

ALCOH

BREAST
CERDEG
CONST
DEGJNT
HERNIA
DIVCOL
DYSPHA
EDEMA
EPILEP
GASTR
GASTRO
GHEMOR

HYPER
HYPOP

BRAINS
OSARTH
PEPULC
RENTUR
COLIO
LEGULC

Agitation
Alcohol dependency
Anorexia
Aortic stenosis
Ataxia
Atrial fibrilation
Atypical psychosis
Benign prostatic hyperplasia
Blindness
Breast disorders
Cerebral degeneration
Clinical obesity
Constipation
Coronary artery disease
Degenerative joint disease (DJD)
Diaphragmatic hernia (hiatal hernia)
Diverticula of colon
Down’s syndrome
Dysphagia (swallowing difficulties)
Edema
Epilepsy
Gastritis/duodenitis
Gastroenteritis, noninfectious
Gastrointestinal hemorrhage
Gout
Hemorrhage of esophagus
Hypercholesterolemia
Hyperlipidemia
Hyperplasia of prostate
Hypopotassemia/hypokalemia
Insomnia
Kyphosis
Nonpsychotic brain syndrome
Organic brain syndrome
Osteoarthritis
Peptic ulcer
Renal ureteral disorder
Scoliosis
Spinal stenosis
Ulcer of leg, chronic
Urinary retention
Vertigo
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________

21

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

AGITAT
.MURIRETCLINOB.MKYPHO.MVERTIANOREX
AOSTENCORART.MORGBRNATAXIA
.MAFIBHESOPHAPSYCH
.MBPRHYPDOWNS.MHYPLIP
BLIND.MSPSTEN

22

.MINSOM
.MGOUT
.MHYPCHO

HA. HEALTH STATUS

BOX HA16

2006 Facility Interview
(Baseline Only)

If comatose (HA11=1), go to HA38.
Else, go to HA34.

DEHYDRATION/DELUSIONS/HALLUCINATIONS
HA34PRE
The next few items are about the other conditions {SP} may have had on or around {REF DATE}. {Again, please
refer to the MDS.}
HA34
Did {SP} experience dehydration on or around {REF DATE}?
DEHYD

YES .............................................................................................
NO................................................................................................

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

23

1
0

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA35
Did {SP} experience delusions on or around {REF DATE}?
DELUS

YES .............................................................................................
NO................................................................................................

1
0

PRESS F1 KEY FOR COMPLETE DEFINITIONS.
HA36
Did {SP} experience hallucinations on or around {REF DATE}?
HALLUC

YES .............................................................................................
NO................................................................................................

1
0

PRESS F1 KEY FOR COMPLETE DEFINITIONS.

ORAL/NUTRITIONAL STATUS
HA37
Did {SP} experience any of the following oral problems on or around {REF DATE}:
{VARIABLE PART OF QUESTION}?
ONCHEW
ONSWALL
ONMOUTHP

BOX HA16A

CHEWING PROBLEM
SWALLOWING PROBLEM
MOUTH PAIN
NONE CHECKED
DON'T KNOW

If PERS.PERSRNDC = current round, or current round is fall round, continue.
Else, go to HA39

HA38
What {is/was} {SP}'s height in inches?
HEIGHT

________
INCHES

HA39
What was {SP}'s weight on or around {REF DATE}?
WEIGHT

BOX HA17

________
POUNDS

If Baseline or Core, go to HA40. If Time 2, go to HC2.

24

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

DENTAL HEALTH
HA40
Please tell me which of the following items describe the condition of {SP}'s dental health on or around
{REF DATE}. Did {she/he} have:
{VARIABLE PART OF QUESTION}?
DHDEBRIS
DHBRIDGE
DHTEELOS
DHBROKEN
DHINFGUM

DEBRIS IN MOUTH
DENTURES OR REMOVABLE BRIDGE
SOME/ALL NATURAL TEETH LOST
BROKEN, LOOSE, OR CARIOUS TEETH
INFLAMED, SWOLLEN, OR BLEEDING GUMS;
ORAL ABSCESSES, ULCERS, OR RASHES
NONE CHECKED
DON'T KNOW

DIAGNOSES/CONDITIONS
NOT ON MDS
HA32
(The rest of the health status questionnaire not from the MDS.)
Can you add any other active diagnoses for {SP} on or around {REF DATE} that have not yet been mentioned?
Please refer to the medical record including {SP's} medications chart for {REF DATE MONTH}.
YES.........................................................
NO ..........................................................
DK...........................................................
RF ...........................................................
PRESS F1 KEY FOR COMPLETE DEFINITIONS.

25

1
0
-8
-7

(BOX HA15A)
(BOX HA15A)
(BOX HA15A)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA33

SHOW
CARD
HA5

What were the diagnoses?
ENTER ICD-9 CODES, IF AVAILABLE, WHEN DIAGNOSES TEXT IS MISSING OR ILLEGIBLE.

Agitation
Alcohol Dependency
Anorexia
Aortic stenosis
Ataxia
Atrial fibrilation
Atypical psychosis
Benign prostatic hyperplasia
Blindness
BREAST
Breast disorders
CERDEG
Cerebral degeneration
Clinical obesity
CONST
Constipation
Coronary artery disease
DEGJNT
Degenerative joint disease (DJD)
HERNIA
Diaphragmatic hernia (hiatal hernia)
DIVCOL
Diverticula of colon
Down’s syndrome
DYSPHA
Dysphagia (swallowing difficulties)
EDEMA
Edema
EPILEP
Epilepsy
GASTR
Gastritis/duodenitis
GASTRO
Gastroenteritis, noninfectious
GHEMOR Gastrointestinal hemorrhage
Gout
Hemorrhage of esophagus
Hypercholesterolemia
Hyperlipidemia
HYPER
Hyperplasia of prostate
HYPOP
Hypopotassemia/hypokalemia
Insomnia
Kyphosis
BRAINS
Nonpsychotic brain syndrome
Organic brain syndrome
OSARTH
Osteoarthritis
PEPULC
Peptic ulcer
RENTUR
Renal ureteral disorder
COLIO
Scoliosis
Spinal stenosis
LEGULC
Ulcer of leg, chronic
Urinary retention
Vertigo
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________
OTHER: SPECIFY ___________________
AGITAT
.NMINSOM
.NMURIRETCLINOB.NMKYPHO.NMVERTIANOREX
AOSTENCORART.NMORGBRNATAXIA
.NMGOUT
.NMAFIBHESOPHAPSYCH
.NMHYPCHO
.NMBPRHYPDOWNS.NMHYPLIP
BLIND.NMSPSTEN
ALCOH

26

HA. HEALTH STATUS

BOX
HA15A

2006 Facility Interview
(Baseline Only)

If arthritis, cancer or cardiovascular disease selected in HA28, go to HA33PRE.
Else, go to HA33D.

HA33PRE
{{While you are referring to {SP}'s medical record/{Now}} I have some {additional} questions about the conditions you
mentioned earlier. {These questions cannot be found on the MDS}.

BOX
HA15B

If arthritis selected in HA28, go to HA33A
Else, go to BOX HA15C.

27

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA33A
What part or parts of {SP's} body have been affected by arthritis?
SELECT ALL THAT APPLY
ARTHJOIN
ARTHARMS
ARTHBACK
ARTHLEGS
ARTHNECK
ARTHOTHR

BOX
HA15C

ALL OVER OR JOINTS
ARMS, SHOULDERS OR HANDS
BACK
HIPS, KNEES, FEET OR ANYWHERE ON LEGS
NECK
OTHER
DON'T KNOW

If cancer selected in HA28, go to HA33B.
Else, go to BOX HA15D.

HA33B
Please refer to {SP's} medical record and tell me in what part or parts of the body was the cancer found?
SELECT ALL THAT APPLY
CNRBLADD
CNRBREAS
CNRCERVI
CNRBOWEL
CNRLUNG
CNROVARY
CNRPROST
CNRSKIN
CNRSTOMA
CNRUTERU
CNROTHER

BOX
HA15D

BLADDER
BREAST
CERVIX
COLON, RECTUM, OR BOWEL
LUNG
OVARY
PROSTATE
SKIN
STOMACH
UTERUS
OTHER
DON'T KNOW

If cardiovascular disease selected in HA28, go to HA33C.
Else, go to HA33D.

HA33C
Please refer to {SP's} medical record and tell me if the cardiovascular disease was angina pectoris or coronary
heart disease?
CRDVTYPE

YES .............................................................................................
NO...............................................................................................

1
0

HA33D
Still referring to the medical record, has {SP} ever had a myocardial infarction or heart attack?
MYOCARD

YES .............................................................................................
NO...............................................................................................

28

1
0

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

VISION
HA33E
Has {SP} ever had an operation for cataracts?
YES .............................................................................................
NO...............................................................................................

CATAROP

BOX
HA15F

1
0

If Core, go to BOX HA17B.
If SP is 65 or older, go to BOX HA17B.
If number of yes responses is 0, go to HA33G.
Else, go to HA33F.

CONDITIONS LINKED TO MEDICARE
HA33F
You told me that {SP} has had {MEDICAL CONDITIONS TO WHICH RESPONDENT ANSWERED YES IN
HA28-HA33E}. {Was this/Were any of these} the original cause of {SP's} becoming eligible for Medicare?
YES .............................................................................................
NO...............................................................................................
DK ...............................................................................................

1
0
-8

(BOX HA15E)
(BOX HA17B)

HA33G
What was the original cause of {SP's} becoming eligible for Medicare?
RECORD VERBATIM

(BOX HA17B)

BOX
HA15E

If more than one condition to which respondent answered yes in HA28-HA33E, go to
HA33H.
Else, go to BOX HA17B.

HA33H
Which of these conditions was a cause of {him/her} becoming eligible for Medicare?
{ITEMS MENTIONED IN HA28-HA33E)

AGITAT

.MINSOM
.MURIRETCLINOB.MKYPHO.MVERTIANOREX
AOSTENCORART.MORGBRNATAXIA
.MGOUT
.MAFIBHESOPHAPSYCH
.MHYPCHO
.MBPRHYPDOWNS.MHYPLIP
BLIND.MSPSTENAGITAT
.NMINSOM
.NMURIRETCLINOB.NMKYPHO.NMVERTIANOREX
AOSTENCORART.NMORGBRNATAXIA
.NMGOUT
.NMAFIBHESOPHAPSYCH
.NMHYPCHO
.NMBPRHYPDOWNS.NMHYPLIPBLIND.NMSPSTEN

HA41PRE-HA43 OMITTED

29

HA. HEALTH STATUS

BOX
HA17B

2006 Facility Interview
(Baseline Only)

If SP is female, go to HA43APRE.
Else, go to HA43DAPRE.

30

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

MAMMOGRAM/PAP SMEAR/HYSTERECTOMY
HA43APRE
The next items are about procedures {SP} may have had since {MON & DAY OF TODAY'S DATE} a year ago.
HA43A
Since {MON & DAY OF TODAY'S DATE} a year ago has {SP} had a mammogram or breast x-ray?
MAMMOGR

YES..............................................................................................
NO................................................................................................

1
0

HA43B
Since {MON & DAY OF TODAY'S DATE} a year ago has {SP} had a Pap smear?
PAPSMEAR

YES .............................................................................................
NO...............................................................................................

1
0

If Baseline, go to HA43D.
BOX
HA17C

Else, go to HA43C.

HA43C
Since {MON & DAY OF TODAY'S DATE} a year ago has {SP} had a hysterectomy?
HYSTEREC

YES .............................................................................................
NO...............................................................................................

1
0

(HA43DC)
(HA43DC)

1
0

(HA43DC)
(HA43DC)

HA43D
Has {SP} ever had a hysterectomy?
EVERHYST

YES .............................................................................................
NO...............................................................................................

HA43DA
Since {MON & DAY OF TODAY'S DATE} a year ago has {SP} had a digital rectal examination of the prostate?
YES.........................................................
NO ..........................................................

DRECEXAM

1
0

HA43DB
Since {MON & DAY OF TODAY'S DATE} a year ago has {SP} had a blood test for detection of prostate cancer, such
as a PSA?
YES.........................................................
NO ..........................................................

BLOODPSA

BOX 17CB

If fall round, continue.
Else, go to BOX 17CA.

31

1
0

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA43DC
Next, a question or two about shots people take to prevent certain illnesses. Did {SP} have a flu shot for last winter
(September through December {YEAR-1})?
FLUSHOT

BOX
HA17CA

YES.........................................................
NO ..........................................................

1
0

If core and HA43DD ever = 1, go to HA43E.
Else, continue..

HA43DD
Has {SP} ever had a shot for pneumonia?
PNUESHOT

YES........................................................
NO..........................................................

32

1
0

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

SMOKING
HA43E
The next couple of questions are about smoking. Has {SP} ever smoked cigarettes, cigars, or pipe tobacco?
YES..............................................................................................
NO................................................................................................

EVRSMOKE

BOX
HA17D

1
0

If comatose (HA11=1), go to BOX HA24.
If HA43E=1 and alive, go to HA43F.
Else, go to HA43GPRE.

HA43F
Does {SP} smoke now?
NOWSMOKE

YES..............................................................................................
NO................................................................................................

1
0

IADLS
HA43GPRE
Now I'm going to ask about how difficult it was, on the average, for {SP} to do certain kinds of activities on or around
{REF DATE}. Please tell me for each activity whether {SP} had no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or is not able to do it.
HA43G
On or around {REF DATE}, how much difficulty, if any, did {SP} have
CODE LEVEL OF DIFFICULTY
SHOW
CARD
HA6

IADSTOOP
IADLIFT
IADREACH
IADGRASP
IADWALK
0.
1.
2.
3.
4.

A.
B.
C.
D.
E.

STOOPING/COUCHING/KNEELING .............................
LIFTING HEAVY OBJECTS ...........................................
REACHING/EXTENDING ARMS....................................
WRITING/GRASPING SMALL OBJECTS ......................
WALKING QUARTER OF A MILE..................................

NO DIFFICULTY AT ALL
A LITTLE DIFFICULTY
SOME DIFFICULTY
A LOT OF DIFFICULTY
NOT ABLE TO DO IT

33

(
(
(
(
(

)
)
)
)
)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA43H
Now I'm going to ask about some everyday activities and whether {SP} had any difficulty doing them by
{himself/herself} because of a health or physical problem on or around {REF DATE}.
Did {SP} have any difficulty on or around {REF DATE} ...
YES=1, NO=0
DOESN'T DO=3
DIFUSEPH
DIFSHOP
DIFMONEY

BOX
HA17E

using the telephone? ..............................................................................
shopping for personal items (such as toilet items or medicines)? ..........
managing money (like keeping track of money or paying bills) ..............

( )
( )
( )

If any item in HA43H coded DOESN'T DO (3), go to HA43I. Else, go to HA43J.

HA43I
You said that {HA43H ITEM CODED 3 (DOESN'T DO)} is something that {SP} doesn't do. Is this because of a health or
physical problem?
YES=1,NO=0
REASNOPH
REASNOSH
REASNOMM

BOX
HA17F

USING TELEPHONE...................................................................
SHOPPING ..................................................................................
MANAGING MONEY ...................................................................

If SP is alive, continue.
Else, go to BOX HA24.

34

(
(
(

)
)
)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

GENERAL HEALTH NOT ON MDS
HA43J
{Finally, I have a few questions on {SP's} general health.}
In general, compared to other people of {his/her} age, would you say that {SP's} health is excellent, very good, good, fair
or poor?
SPHEALTH

EXCELLENT ................................................................................
VERY GOOD ...............................................................................
GOOD..........................................................................................
FAIR.............................................................................................
POOR ..........................................................................................

35

0
1
2
3
4

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

HA43K
Compared to one year ago, how would you rate SP's health in general now? Would you say SP's health is . . .
GENHLTH

much better now than one year ago, ............................................
somewhat better now than one year ago,.....................................
about the same, ...........................................................................
somewhat worse now than one year ago, or ................................
much worse now than one year ago?...........................................

0
1
2
3
4

HA43L
How much of the time during the past month has {his/her} health limited SP's social activities, like visiting with friends
or close relatives? Would you say . . .
LIMACTIV

BOX HA24

none of the time, ..........................................................................
some of the time,..........................................................................
most of the time, or ......................................................................
all of the time?..............................................................................

0
1
2
3

If Baseline and if SP was a resident in an eligible unit of the facility at FAD+90 and
if FAD+120 < the round interview date, and if HA T2 not complete, go to BOX
HA1.
Else, go to HC2.

RESPONDENT SCREEN
HC2
DID YOU ABSTRACT?
ALL..............................................................................................
MAJORITY ..................................................................................
HALF ...........................................................................................
SOME..........................................................................................
NONE..........................................................................................

1
2
3
4
5

HC3
WHY DID YOU ABSTRACT?
NO KNOWLEDGEABLE RESPONDENT AVAILABLE ...............
NO TIME/STAFF BURDEN TOO GREAT...................................
REFUSAL--UNWILLING TO COOPERATE ................................
OTHER, (SPECIFY:_____________________) .........................
HCEND
YOU HAVE COMPLETED THE HEALTH STATUS SECTION FOR THIS SP.
PRESS ENTER TO RETURN TO THE NAVIGATION SCREEN.

36

1
2
3
91

(HCEND)

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

GoutHemorrhage of
esophagusHypercholesterolemia

Alcohol Dependency

Hyperlipidemia

Anorexia

Insomnia

Aortic stenosis

Kyphosis

Ataxia

Organic brain syndrome

Atrial fibrilation

Osteoarthritis

Atypical psychosis

Spinal stenosis

Blindness

Urinary retention

Benign prostatic hyperplasia

Vertigo

Breast Disorders
Cerebral Degeneration
Clinical obesity
Constipation
Coronary artery disease
Degenerative joint disease (DJD)
Diaphragmatic Hernia (Hiatal
Hernia)
Diverticula of Colon
Down’s syndrome
Dysphagia (swallowing
difficulties)
Edema

37

HA. HEALTH STATUS

2006 Facility Interview
(Baseline Only)

38