Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

The Centers for Medicare & Medicaid Services' Office of Research, Development, and Information (ORDI) strives to make information available to all.
Nevertheless, portions of our files including charts, tables, and graphics may be difficult to read using assistive technology.
In some cases due to size or complexity, we were not able to make files fully accessible using assistive technology. Persons with disabilities
experiencing problems accessing portions of any file should contact ORDI through e-mail at [email protected].

BOX PA1

BOX PA1

Page Order # :

10

BOX INSTRUCTIONS
( PAQ1005 )

GO TO PAINTRO - PAINTRO ( PAQ1010 ).

ASSIGNMENTS
Create a current round PACT record where PACT.PACTRND = current round and
PACT.PACTRESP = 01.
PACT Key = PACT.PACTBASE + PACT.PACTRND + PACT.PACTRESP.
See instructions below.
PACTRND

PACT.PACTRND = current round.

PACTRESP

PACT.PACTRESP = 01.

TECHNICAL NOTES

DESIGN NOTES

1:23:45 PM Friday, February 12, 2010

Page 1 of 42

PAINTRO

PAINTRO

Page Order # :

Design Screen Type:

No Entry

Fields:

Field 1:

PAINTRO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

20

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:
Question Text:

Now I have some questions about how you make health care
decisions. Answers to questions like these will help Medicare better
understand how people use medical services.
Please keep in mind that there are no right or wrong answers to
these questions. Your opinions and experiences are important to us.

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:45 PM Friday, February 12, 2010

Page 2 of 42

PAINTRO
PAINTRO

Field1:

( PAQ1010 )

TEMP

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TContinueEMPTY
1
No
No

Number Label
1 Continue

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA1 - PANECESS ( PAQ1015 )

English text: CONTINUE
Attribute
Empty

Route
PA1 - PANECESS ( PAQ1015 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:46 PM Friday, February 12, 2010

Page 3 of 42

PA1

PA1

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PANECESS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

30

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA1

Question Text:

Please tell me how confident you are that you can identify when it is
necessary for you to get medical care.

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:46 PM Friday, February 12, 2010

Page 4 of 42

PA1
PANECESS

Field1:

( PAQ1015 )

PACT.PANECESS

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TConfdnt
1
No
No

Number Label
1 VeryConfident

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA2 - PASIDEFX ( PAQ1020 )

English text: VERY CONFIDENT
2

Confident

PA2 - PASIDEFX ( PAQ1020 )

3

English text: CONFIDENT
SomewhatConfident

PA2 - PASIDEFX ( PAQ1020 )

English text: SOMEWHAT CONFIDENT
4

NotAtAllConfident

PA2 - PASIDEFX ( PAQ1020 )

English text: NOT AT ALL CONFIDENT
Attribute
Don't know

Route
PA2 - PASIDEFX ( PAQ1020 )

Refusal

PA2 - PASIDEFX ( PAQ1020 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:46 PM Friday, February 12, 2010

Page 5 of 42

PA2

PA2

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PASIDEFX

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

40

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[How confident are you that you can...]" in brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA1

Question Text:

[How confident are you that you can...]
Identify when you are having side effects from your medications?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:46 PM Friday, February 12, 2010

Page 6 of 42

PA2
PASIDEFX

Field1:

( PAQ1020 )

PACT.PASIDEFX

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TConfdna
1
No
No

Number Label
1 VeryConfident

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA3 - PAINSTRC ( PAQ1025 )

English text: VERY CONFIDENT
2

Confident

PA3 - PAINSTRC ( PAQ1025 )

3

English text: CONFIDENT
SomewhatConfident

PA3 - PAINSTRC ( PAQ1025 )

English text: SOMEWHAT CONFIDENT
4

NotAtAllConfident

PA3 - PAINSTRC ( PAQ1025 )

English text: NOT AT ALL CONFIDENT
5

NotApplicable

PA3 - PAINSTRC ( PAQ1025 )

English text: NOT APPLICABLE
Attribute
Don't know

Route
PA3 - PAINSTRC ( PAQ1025 )

Refusal

PA3 - PAINSTRC ( PAQ1025 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

1:23:47 PM Friday, February 12, 2010

Page 7 of 42

PA2
DESIGN NOTES

1:23:47 PM Friday, February 12, 2010

Page 8 of 42

PA3

PA3

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PAINSTRC

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

50

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA1

Question Text:

Doctors often give instructions about how you should care for
yourself at home, like changing a bandage, taking medicines on
schedule, or applying ice packs. How confident are you that you can
follow instructions to care for yourself at home?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:47 PM Friday, February 12, 2010

Page 9 of 42

PA3
PAINSTRC

Field1:

( PAQ1025 )

PACT.PAINSTRC

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TConfdna
1
No
No

Number Label
1 VeryConfident

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA4 - PAMEDREC ( PAQ1030 )

English text: VERY CONFIDENT
2

Confident

PA4 - PAMEDREC ( PAQ1030 )

3

English text: CONFIDENT
SomewhatConfident

PA4 - PAMEDREC ( PAQ1030 )

English text: SOMEWHAT CONFIDENT
4

NotAtAllConfident

PA4 - PAMEDREC ( PAQ1030 )

English text: NOT AT ALL CONFIDENT
5

NotApplicable

PA4 - PAMEDREC ( PAQ1030 )

English text: NOT APPLICABLE
Attribute
Don't know

Route
PA4 - PAMEDREC ( PAQ1030 )

Refusal

PA4 - PAMEDREC ( PAQ1030 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

1:23:47 PM Friday, February 12, 2010

Page 10 of 42

PA3
DESIGN NOTES

1:23:47 PM Friday, February 12, 2010

Page 11 of 42

PA4

PA4

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PAMEDREC

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

60

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA1

Question Text:

Doctors also often give instructions about changing your habits or
lifestyle, such as changing your diet, stopping smoking, or getting
regular exercise. How confident are you that you can follow this kind
of instruction, to change your habits or lifestyle?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:48 PM Friday, February 12, 2010

Page 12 of 42

PA4
PAMEDREC

Field1:

( PAQ1030 )

PACT.PAMEDREC

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TConfdnt
1
No
No

Number Label
1 VeryConfident

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA5 - PACHGDRS ( PAQ1035 )

English text: VERY CONFIDENT
2

Confident

PA5 - PACHGDRS ( PAQ1035 )

3

English text: CONFIDENT
SomewhatConfident

PA5 - PACHGDRS ( PAQ1035 )

English text: SOMEWHAT CONFIDENT
4

NotAtAllConfident

PA5 - PACHGDRS ( PAQ1035 )

English text: NOT AT ALL CONFIDENT
Attribute
Don't know

Route
PA5 - PACHGDRS ( PAQ1035 )

Refusal

PA5 - PACHGDRS ( PAQ1035 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:48 PM Friday, February 12, 2010

Page 13 of 42

PA5

PA5

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PACHGDRS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

70

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA2

Question Text:

Please use this card to respond to the following statements.
How likely are you to change doctors if you are dissatisfied with the
way you and your doctor communicate?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:48 PM Friday, February 12, 2010

Page 14 of 42

PA5
PACHGDRS

Field1:

( PAQ1035 )

PACT.PACHGDRS

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TLikely
1
No
No

Number Label
1 VeryLikely

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA6 - PADISAGR ( PAQ1040 )

English text: VERY LIKELY
2

Likely

PA6 - PADISAGR ( PAQ1040 )

3

English text: LIKELY
Unlikely

PA6 - PADISAGR ( PAQ1040 )

English text: UNLIKELY
4

VeryUnlikely

PA6 - PADISAGR ( PAQ1040 )

English text: VERY UNLIKELY
Attribute
Don't know

Route
PA6 - PADISAGR ( PAQ1040 )

Refusal

PA6 - PADISAGR ( PAQ1040 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:48 PM Friday, February 12, 2010

Page 15 of 42

PA6

PA6

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PADISAGR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

80

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA2

Question Text:

How likely are you to tell your doctor when you disagree with him or
her?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:49 PM Friday, February 12, 2010

Page 16 of 42

PA6
PADISAGR

Field1:

( PAQ1040 )

PACT.PADISAGR

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TLikely
1
No
No

Number Label
1 VeryLikely

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA9 - PAHCONDS ( PAQ1045 )

English text: VERY LIKELY
2

Likely

PA9 - PAHCONDS ( PAQ1045 )

3

English text: LIKELY
Unlikely

PA9 - PAHCONDS ( PAQ1045 )

English text: UNLIKELY
4

VeryUnlikely

PA9 - PAHCONDS ( PAQ1045 )

English text: VERY UNLIKELY
Attribute
Don't know

Route
PA9 - PAHCONDS ( PAQ1045 )

Refusal

PA9 - PAHCONDS ( PAQ1045 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:49 PM Friday, February 12, 2010

Page 17 of 42

PA9

PA9

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PAHCONDS

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

100

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

These next questions are about practices sometimes associated
with receiving medical care. Please tell me if you always, usually,
sometimes, or never do the following:
Do you always, usually, sometimes, or never read about health
conditions in newspapers, magazines, or on the Internet?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:49 PM Friday, February 12, 2010

Page 18 of 42

PA9
PAHCONDS

Field1:

( PAQ1045 )

PACT.PAHCONDS

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA10 - PARXINFO ( PAQ1050 )

English text: ALWAYS
2

Usually

PA10 - PARXINFO ( PAQ1050 )

3

English text: USUALLY
Sometimes

PA10 - PARXINFO ( PAQ1050 )

English text: SOMETIMES
4

Never

PA10 - PARXINFO ( PAQ1050 )

English text: NEVER
Attribute
Don't know

Route
PA10 - PARXINFO ( PAQ1050 )

Refusal

PA10 - PARXINFO ( PAQ1050 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:49 PM Friday, February 12, 2010

Page 19 of 42

PA10

PA10

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PARXINFO

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

110

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Read information about a new prescription, such as side effects and
precautions?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:50 PM Friday, February 12, 2010

Page 20 of 42

PA10
PARXINFO

Field1:

( PAQ1050 )

PACT.PARXINFO

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA11 - PADRQUEX ( PAQ1055 )

English text: ALWAYS
2

Usually

PA11 - PADRQUEX ( PAQ1055 )

3

English text: USUALLY
Sometimes

PA11 - PADRQUEX ( PAQ1055 )

English text: SOMETIMES
4

Never

PA11 - PADRQUEX ( PAQ1055 )

English text: NEVER
Attribute
Don't know

Route
PA11 - PADRQUEX ( PAQ1055 )

Refusal

PA11 - PADRQUEX ( PAQ1055 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:50 PM Friday, February 12, 2010

Page 21 of 42

PA11

PA11

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PADRQUEX

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

120

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Bring with you to your doctor visits a list of questions or concerns
you want to cover?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:50 PM Friday, February 12, 2010

Page 22 of 42

PA11
PADRQUEX

Field1:

( PAQ1055 )

PACT.PADRQUEX

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA12 - PAANSWR ( PAQ1060 )

English text: ALWAYS
2

Usually

PA12 - PAANSWR ( PAQ1060 )

3

English text: USUALLY
Sometimes

PA12 - PAANSWR ( PAQ1060 )

English text: SOMETIMES
4

Never

PA12 - PAANSWR ( PAQ1060 )

English text: NEVER
Attribute
Don't know

Route
PA12 - PAANSWR ( PAQ1060 )

Refusal

PA12 - PAANSWR ( PAQ1060 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:50 PM Friday, February 12, 2010

Page 23 of 42

PA12

PA12

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PAANSWR

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

130

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Leave your doctor's office feeling that all of your concerns or
questions have been fully answered?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:50 PM Friday, February 12, 2010

Page 24 of 42

PA12
PAANSWR

Field1:

( PAQ1060 )

PACT.PAANSWR

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA13 - PALISTRX ( PAQ1065 )

English text: ALWAYS
2

Usually

PA13 - PALISTRX ( PAQ1065 )

3

English text: USUALLY
Sometimes

PA13 - PALISTRX ( PAQ1065 )

English text: SOMETIMES
4

Never

PA13 - PALISTRX ( PAQ1065 )

English text: NEVER
Attribute
Don't know

Route
PA13 - PALISTRX ( PAQ1065 )

Refusal

PA13 - PALISTRX ( PAQ1065 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:51 PM Friday, February 12, 2010

Page 25 of 42

PA13

PA13

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PALISTRX

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

140

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Take a list of all of your prescribed medicines to your doctor visits?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:51 PM Friday, February 12, 2010

Page 26 of 42

PA13
PALISTRX

Field1:

( PAQ1065 )

PACT.PALISTRX

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysNA
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA14 - PATRSLT ( PAQ1070 )

English text: ALWAYS
2

Usually

PA14 - PATRSLT ( PAQ1070 )

3

English text: USUALLY
Sometimes

PA14 - PATRSLT ( PAQ1070 )

English text: SOMETIMES
4

Never

PA14 - PATRSLT ( PAQ1070 )

English text: NEVER
5

NotApplicable

PA14 - PATRSLT ( PAQ1070 )

English text: NOT APPLICABLE
Attribute
Don't know

Route
PA14 - PATRSLT ( PAQ1070 )

Refusal

PA14 - PATRSLT ( PAQ1070 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

1:23:51 PM Friday, February 12, 2010

Page 27 of 42

PA13
DESIGN NOTES

1:23:51 PM Friday, February 12, 2010

Page 28 of 42

PA14

PA14

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PATRSLT

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

150

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.
Always display "(An example would be...)" in parentheses.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Make sure you understand the results of any medical test or
procedure such as an x-ray, blood test, or EKG for heart conditions?

Int. Instr II:

1:23:52 PM Friday, February 12, 2010

Page 29 of 42

PA14
INPUT FIELDS / ROUTING
PATRSLT

Field1:

( PAQ1070 )

PACT.PATRSLT

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA15 - PAOPTION ( PAQ1075 )

English text: ALWAYS
2

Usually

3

Sometimes

PA15 - PAOPTION ( PAQ1075 )

English text: USUALLY
PA15 - PAOPTION ( PAQ1075 )

English text: SOMETIMES
4

Never

PA15 - PAOPTION ( PAQ1075 )

English text: NEVER
Attribute
Don't know

Route
PA15 - PAOPTION ( PAQ1075 )

Refusal

PA15 - PAOPTION ( PAQ1075 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
1:23:52 PM Friday, February 12, 2010

Page 30 of 42

PA14

1:23:52 PM Friday, February 12, 2010

Page 31 of 42

PA15

PA15

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PAOPTION

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

160

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Do you always, usually, sometimes, or never...]" in
brackets.
Always display "(An example would be...)" in parentheses.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

[Do you always, usually, sometimes, or never...]
Talk with your doctor or other medical person about your options if
you need tests, follow-up care, or a referral for care by a medical
specialist?

Int. Instr II:

1:23:52 PM Friday, February 12, 2010

Page 32 of 42

PA15
INPUT FIELDS / ROUTING
PAOPTION

Field1:

( PAQ1075 )

PACT.PAOPTION

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA16 - PADRLISN ( PAQ1080 )

English text: ALWAYS
2

Usually

3

Sometimes

PA16 - PADRLISN ( PAQ1080 )

English text: USUALLY
PA16 - PADRLISN ( PAQ1080 )

English text: SOMETIMES
4

Never

PA16 - PADRLISN ( PAQ1080 )

English text: NEVER
Attribute
Don't know

Route
PA16 - PADRLISN ( PAQ1080 )

Refusal

PA16 - PADRLISN ( PAQ1080 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
1:23:53 PM Friday, February 12, 2010

Page 33 of 42

PA15

1:23:53 PM Friday, February 12, 2010

Page 34 of 42

PA16

PA16

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PADRLISN

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

170

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:

Always display "[Does that always, usually, sometimes, or never
happen?]" in brackets.

Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

Now I am going to read some statements that may describe your
relationship with your doctor. Please tell me if the following
statements always, usually, sometimes, or never happen.
My doctor listens to what I have to say about my symptoms and
concerns. [Does that always, usually, sometimes, or never happen?]

Int. Instr II:

1:23:53 PM Friday, February 12, 2010

Page 35 of 42

PA16
INPUT FIELDS / ROUTING
PADRLISN

Field1:

( PAQ1080 )

PACT.PADRLISN

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA20 - PADREXPL ( PAQ1085 )

English text: ALWAYS
2

Usually

3

Sometimes

PA20 - PADREXPL ( PAQ1085 )

English text: USUALLY
PA20 - PADREXPL ( PAQ1085 )

English text: SOMETIMES
4

Never

PA20 - PADREXPL ( PAQ1085 )

English text: NEVER
Attribute
Don't know

Route
PA20 - PADREXPL ( PAQ1085 )

Refusal

PA20 - PADREXPL ( PAQ1085 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES
1:23:53 PM Friday, February 12, 2010

Page 36 of 42

PA16

1:23:53 PM Friday, February 12, 2010

Page 37 of 42

PA20

PA20

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PADREXPL

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

180

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

My doctor explains things to me in terms that I can easily
understand. Does that always, usually, sometimes, or never
happen?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:53 PM Friday, February 12, 2010

Page 38 of 42

PA20
PADREXPL

Field1:

( PAQ1085 )

PACT.PADREXPL

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
PA21 - PADVICE ( PAQ1090 )

English text: ALWAYS
2

Usually

PA21 - PADVICE ( PAQ1090 )

3

English text: USUALLY
Sometimes

PA21 - PADVICE ( PAQ1090 )

English text: SOMETIMES
4

Never

PA21 - PADVICE ( PAQ1090 )

English text: NEVER
Attribute
Don't know

Route
PA21 - PADVICE ( PAQ1090 )

Refusal

PA21 - PADVICE ( PAQ1090 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:54 PM Friday, February 12, 2010

Page 39 of 42

PA21

PA21

Page Order # :

Design Screen Type:

Code 1

Fields:

Field 1:

PADVICE

Enable Functions:

HELP
COMMENTS
JUMPBACK

No
Yes
Yes

Roster Functions:

Add Item
Edit Item
Delete Item
Search Item

No
No
No
No

Grid Functions:

Add Line
Delete Line

No
No

190

Roster Name:
Roster Type:

DISPLAY INSTRUCTIONS:
Context header display:
Question display:
Multi Field display:

Roster/Grid Instructions:
Roster/Grid display:
Report display:

TEXT:
Context Header:
Int. Instr I:

SHOW CARD PA4

Question Text:

I can call my doctor's office to get medical advice when I need it.
Does that always, usually, sometimes, or never happen?

Int. Instr II:
INPUT FIELDS / ROUTING

1:23:54 PM Friday, February 12, 2010

Page 40 of 42

PA21
PADVICE

Field1:

( PAQ1090 )

PACT.PADVICE

Cheshire Name:
Item Text display:
Item Text:
Label:
Label Position:
Field Type:
Type Name:
Answers Allowed:
Drop Down List:
Lookup File:
Lookup File Name:

Enumerated
TAlwaysUsually
1
No
No

Number Label
1 Always

FieldSize:
Min Value:
Max Value:
Mask:

Route
BOX PA2 - (PAQ1095 )

English text: ALWAYS
2

Usually

BOX PA2 - (PAQ1095 )

3

English text: USUALLY
Sometimes

BOX PA2 - (PAQ1095 )

English text: SOMETIMES
4

Never

BOX PA2 - (PAQ1095 )

English text: NEVER
Attribute
Don't know

Route
BOX PA2 - (PAQ1095 )

Refusal

BOX PA2 - (PAQ1095 )

BACKGROUND VARIABLE ASSIGNMENTS

SOFT EDIT CHECKS

HARD EDIT CHECKS

TECHNICAL NOTES

DESIGN NOTES

1:23:54 PM Friday, February 12, 2010

Page 41 of 42

BOX PA2

BOX PA2

Page Order # :

200

BOX INSTRUCTIONS
( PAQ1095 )

GO TO NEXT SECTION .

ASSIGNMENTS

TECHNICAL NOTES

DESIGN NOTES

1:23:54 PM Friday, February 12, 2010

Page 42 of 42