Attachment D R79 PMQ revisions (Feb 2017 non-sub change request)

Prescribed Medicine Utilization (PMQ)
Variable Name

MR Screen Name

Question text/description

Code list

[Now let’s talk about prescribed medicines [you have/(SP) has] obtained since (REFERENCE
DATE/UTILDATE).]
PMINTA

PMINTROA

[While talking about medical visits, you mentioned some medicine(s): [READ MEDICINE NAME(S) BELOW.]]
[Now I’d like to talk about prescribed medicines.]

PMFILLED

PM1

BOX PMA1

PM1PMMEDS

PM1A

[Besides that medicine, /Besides those medicines, ] [(Since/since) (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)] [have you had/has (SP) had/did (SP) have] any (other) prescriptions
filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN IT
WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO
TO PM1A - PM1PMMEDS.
ELSE GO TO PM2 - MEDICINE_PM1.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I
can spell the medicine name correctly and enter the strength of the medicine. [Also, please take out
[your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that
same information on them.]

(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP DO NOT
DISPLAY.DATA EDITING ONLY.
(-8) DON'T KNOW
(-9) REFUSED

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[AT TOP OF SCREEN DISPLAY LINK TO PRESCRIBED MEDICINE LOOKUP WITH LABEL "Search Medicine"]
MEDICINE_PM1

PM2

Please tell me the names of these medicines.
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)

PMEDNAME

PM2

PMSTRUNI

PM2

MEDID

PM2

ADDP

PM2B

(01) CONTINUOUS ANSWER
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[PRESCRIPTION MEDICINE LOOKUP CALLED FROM THIS SCREEN]
STRENGTH:
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[DISPLAY MEDICINE ROSTER]

(01) ADD ANOTHER
(02) ALL DONE

People sometimes forget to mention refills of earlier prescriptions. (In addition to what you’ve told me
about, did/Did) [you/(SP)] have any prescriptions refilled [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
PMREFILL

PM3

BOX PMA2

PM2PMMEDS

PM3A

[COUNT A MEDICINE AS "REFILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN IT
WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO
TO PM3A - PM2PMMEDS.
ELSE GO TO PM4 - MEDICINE_PM2.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I
can spell the medicine name correctly and enter the strength of the medicine. [Also, please take out
[your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that
same information on them.]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
(01) CONTINUOUS ANSWER
[AT TOP OF SCREEN DISPLAY LINK TO PRESCRIBED MEDICINE LOOKUP WITH LABEL "Search Medicine"]

MEDICINE_PM2

PM4

Please tell me all the names of these medicines.
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)

[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

PMEDNAME

PM4

PMSTRUNI

PM4

MEDID

PM4

ADDP

PM4B

PMDRPHON

PM5

What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[PRESCRIPTION MEDICINE LOOKUP CALLED FROM THIS SCREEN]
STRENGTH:
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[DISPLAY MEDICINE ROSTER]
People sometimes forget to mention prescriptions that were phoned in by a doctor. (In addition to what
you’ve told me about, did/Did) [you/(SP)] get any medicine prescribed by a doctor or other health
professional in a telephone call to a drugstore or pharmacy [since (REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)]?
[INLCUDE ALL PRESCRIBED MEDICINES REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN
IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
RESPONDENT ACTUALLY TOOK THE MEDICINE.]

(01) ADD ANOTHER
(02) ALL DONE

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

BOX PMA3

PM3PMMEDS

PM5A

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO
TO PM5A - PM3PMMEDS.
ELSE GO TO PM6 - MEDICINE_PM3.
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I
can spell the medicine name correctly and enter the strength of the medicine. [Also, please
take out [your/(SP's)] (MEDICARE PRESCRIPTION DRUG PLAN
NAME) medicine statements, which should have that same
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since the last interview, if you’d like to get those bottles, too.
(01) CONTINUOUS ANSWER
[AT TOP OF SCREEN DISPLAY LINK TO PRESCRIBED MEDICINE LOOKUP WITH LABEL "Search Medicine"]

MEDICINE_PM3

PM6

Please tell me the names of these medicines.
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
[DISPLAY ROSTER WITH ALL MEDICINES FROM PRIOR ROUNDS (WHERE EVENT.EVNTTYPE='PM' AND
EVNTDFLG^=1)]
DISPLAY MEDICINE NAME (EVENT.PMEDNAME) AND STRENGTH (EVENT.PRMSTRUNI)

[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR
EACH.
IF NO EXISTING MEDICINES DISPLAY "NO MEDICINES
LISTED"]

What is the name of the medicine?
SELECT OR ADD ALL MEDICINES AT THIS ROSTER.
CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.

PMEDNAME

PM6

PMSTRUNI

PM6

MEDID

PM6

ADDP

PM6AA

[DISPLAY MEDICINE ROSTER]

BOX PM1

IF SP REPORTED AT LEAST ONE PRESCRIPTION MEDICINE IN THE CURRENT ROUND UTILIZATION THAT DOES
NOT HAVE NUMBER OF PURCHASES ENTERED, GO TO PM6A - GETNUM.
ELSE GO TO PM17 - PMMORE.

[PRESCRIPTION MEDICINE LOOKUP CALLED FROM THIS SCREEN]
STRENGTH:
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
(01) ADD ANOTHER
(02) ALL DONE

How many times [since (REFERENCE DATE/UTILDATE)) between (REFERENCE DATE) and (DATE OF
DEATH/DATE OF INSTITUTIONALIZATION/ENDUTIL)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM

PM6A

BOX PM1A
NAVIGATOR

PM6A_IN

(01) continuous answer
IF ALL MEDICINES ARE NOT LISTED, USE "PREVIOUS PAGE" AND ADD THE MEDICINE TO THE ROSTER. REFER (996) EVENT ENTERED IN ERROR
TO STATEMENTS OR RECEIPTS, IF AVAILABLE.
(-8) Don't Know
(-9) Refused
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]
IF AT LEAST ONE PRESCRIPTION MEDICINE DISPLAYED AT PM6A HAS NUMBER OF PURCHASES > 0 OR
EQUAL TO DK OR RF, GO TO PM6A_IN - NAVIGATOR.
ELSE GO TO PM17 - PMMORE.
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

BOX PM1A-1

PMSATVA

PM6A1

BOX PM1AA

PMSATHMO

PM6B

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PM6A1 - PMSATVA.
ELSE GO TO BOX PM1AA.
(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department (02) NO
of Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PM6B - PMSATHMO.
ELSE GO TO PMINTROB - PMINTB.
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED
CARE PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE
PLAN NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMINTB

PMINTROB
BOX PM1B

PMBOTTLE

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

[ASK R TO GET BOTTLES AND/OR STATEMENTS IF YOU HAVE NOT ALREADY DONE SO.]
[Now] I need to ask you a few [more] questions about the (MEDICINE NAME).
GO TO PM8 - PMBOTTLE.

PM8

CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT.
Do you have the medicine bottle, container, or bag available?
IF R DOES NOT HAVE BOTTLE, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE FORM,
STRENGTH, AND QUANTITY OF THE MEDICINE.

BOX PM1B-1

IF (SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND
FORM WAS ASKED AND DID NOT EQUAL DK) AND (SP REPORTED THE PRESCRIPTION MEDICINE IN THE
PREVIOUS ROUND AND THE PREVIOUS ROUND STRENGTH WAS ASKED AND DID NOT EQUAL DK) AND ((SP
REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND NUMBER
WAS ASKED AND DID NOT EQUAL DK) OR (SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS
ROUND AND THE PREVIOUS ROUND AMOUNT WAS ASKED AND DID NOT EQUAL DK)), GO TO PM8AA SAMEFSAM.
IF SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND
FORM WAS ASKED AND DID NOT EQUAL DK, GO TO PM8A - SAMEFORM.
ELSE GO TO BOX PM1B-2A.

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM, STRENGTH
AND AMOUNT ARE THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength of [each pill/each suppository/each patch/the (STRENGTH MEDICINE FORM)] was [READ
STRENGTH BELOW].
SAMEFSAM

PM8AA

(STRENGTH 1)
(STRENGTH 2)
[The amount of the (MEDICINE FORM) in the container when it was obtained was (PREVIOUS ROUND
MEDICINE AMOUNT)./The number of (MEDICINE FORM) in the container when it was obtained was
(PREVIOUS ROUND NUMBER).]
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS STRENGTH, FORM AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

SAMEFORM

PM8A

BOX PM1B-2
BOX PM1B-2A
PMINTROC

CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM IS SAME AS
PREVIOUS INTERVIEW.
(01) YES
(I would like to record what is different about this medicine.)
(02) NO
(-8) DON'T KNOW
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM). (-9) REFUSED
Is this medicine in the same form?
IF SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND AND THE PREVIOUS ROUND
STRENGTH WAS ASKED AND DID NOT EQUAL DK, GO TO PM9A - SAMESTRN.
ELSE GO TO PM10 - STRNUNIT.
IF PM8 - PMBOTTLE=1/Yes, GO TO PMINTROC - PMINTC.
ELSE GO TO PM9 - PMFORM.
COMPLETE PM9 -- PM16 USING INFORMATION FROM STATEMENT, RECEIPT, MEDICINE BOTTLE OR
CONTAINER. IF THERE IS MORE THAN ONE FOR THE SAME MEDICINE, USE THE MOST RECENT CONTAINER.

IN WHAT FORM IS THE MEDICINE?
PMFORM

PM9
[IF THE CONTAINER INDICATES "PADS", SELECT THE CATEGORY FOR "PATCHES'.]

PMFORMOS

SAMESTRN

PM9

OTHER (SPECIFY)
CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND STRENGTH IS
SAME AS PREVIOUS INTERVIEW.
At the time of the last interview, the strength of [each pill/each suppository/each patch/the (MEDICINE
FORM)] was [READ STRENGTH BELOW].

PM9A
(STRENGTH 1)
(STRENGTH 2)

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(01) CONTINUOUS ANSWER

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

Is this medicine in the same strength?

WHAT IS THE STRENGTH OF [EACH PILL/EACH SUPPOSITORY/EACH PATCH/THE (MEDICINE FORM)]?
STRNUNIT

PM10

STRNUNOS

PM10

IF COMPOUND MEDICINE: ENTER STRENGTH OF 1ST MEDICINE, THEN CHECK THE BOX BELOW.

OTHER (SPECIFY)

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED DO NOT DISPLAY.
(-8) Don't Know
(01) CONTINUOUS ANSWER

STRNNUM
STRNPER

PM10
PM10

STRNUNIT96

PM10

ENTER THE NAME OF THE 2ND MEDICINE IN THE COMPOUND IN THE BOX BELOW

BOX PM1B-3

IF PM10 - STRNUNIT96 = 1/Compound, GO TO PM10B - STRNUNI2.
ELSE GO TO BOX PM1B-4.

STRNUNI2

PM10B

WHAT WAS THE STRENGTH OF THE 2ND MEDICINE IN THE COMPOUND?

STRNUNO2
STRNNUM2
STRNPER2

PM10B
PM10B
PM10B

OTHER (SPECIFY)

TABNUM

PERCENT?

BOX PM1B-4

IF PM9A - SAMESTRN = 1/Yes AND SP REPORTED THE PRESCRIPTION MEDICINE IN THE PREVIOUS ROUND
AND THE PREVIOUS ROUND AMOUNT WAS ASKED AND DID NOT EQUAL DK, GO TO PM15A - SAMEAMNT.
ELSE IF THE PRESCRIPTION MEDICINE FORM IS PILLS, SUPPOSITORIES OR PATCHES, GO TO PM11 TABNUM.
ELSE GO TO PM16 - AMTUNIT.

PM11

HOW MANY [PILLS/SUPPOSITORIES/PATCHES] WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

BOX PM1C
TABSADAY

PM12

TABSADAY95

PM12

BOX PM1D

TABTAKE

PM13

TABTAKE96

PM13
BOX PM1E

IF PRESCRIPTION MEDICINE FORM IS PILLS OR SUPPOSITORIES AND PM11 - TABNUM = DK, GO TO PM12 TABSADAY.
ELSE GO TO BOX PM2.
HOW MANY [PILLS/SUPPOSITORIES] ARE TO BE TAKEN IN A DAY?

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) COMPOUND/MORE THAN ONE MEDICINE
COMBINED
(-7) EMPTY

(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(96) COMPOUND/MORE THAN ONE MEDICINE
COMBINED DO NOT DISPLAY.
(-8) Don't Know
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW

(01) CONTINUOUS ANSWER
(01) LESS THAN WHOLE
(02) TAKE AS NEEDED
(-7) Empty

IF PM12 - TABSADAY = DK, GO TO BOX PM2.
ELSE IF PM12 - TABSADAY95 = 2/TakeAsNeeded, GO TO PM13 - TABTAKE.
ELSE GO TO PM14 - TAKEUNIT.
How many (pills/suppositories) (do/did/does) [you/(SP)] usually take in a day?

IF PM13 - TABTAKE96 = 1/DontTakeEveryDay, GO TO BOX PM2.
ELSE GO TO PM14 - TAKEUNIT.

(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) DON'T TAKE EVERY DAY
(-7) EMPTY

HOW MANY DAYS OR WEEKS WAS THE MEDICINE TO BE TAKEN?
TAKEUNIT

PM14

TAKENUM

PM14

[IF THE BOTTLE SAYS TO TAKE A CERTAIN DOSE OF THE MEDICINE DAILY WITHOUT GIVING A TIME FRAME
(E.G., “TAKE 2 PILLS DAILY”), SELECT “TAKE EVERY DAY”.]

SAMEAMNT

PM15A

CODE “YES” WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND AMOUNT IS
SAME AS PREVIOUS INTERVIEW.
At the time of the last interview, the amount of the (PREVIOUS ROUND MEDICINE FORM) was (PREVIOUS
ROUND MEDICINE AMOUNT). Is this medicine in the same amount?

AMTUNIT

PM16

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

AMTUNOS
AMTNUM

PM16
PM16
BOX PM2
BOX PM3A

PMMORE

PM17

OTHER (SPECIFY)

(01) DAYS
(02) WEEKS
(03) TAKE UNTIL GONE
(04) TAKE AS NEEDED
(05) TAKE EVERY DAY
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

GO TO PM6A_IN - NAVIGATOR.
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST43.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS43.
ELSE GO TO PM17 - PMMORE.
([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE NAMES OF
ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED BELOW.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

BOX PM4

IF SPALIVE=1 (ALIVE) AND SEASON=FALL GO TO SC15-PMNOTGET. ELSE GO TO BOX PMEND.

PMNOTGET

SC15

During (CURRENT YEAR) were any medicines prescribed for [you/(SP)] that [you/he/she] did not get?
Please include refills of earlier prescriptions as well as prescriptions that were written or phoned in by a
doctor or other health professional.

TEMPMED1

SC16

TEMPMED2

SC16

TEMPMED3

SC16

TEMPMED4

SC16

TEMPMED5

SC16

What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.
What were the names of those medicines?
ENTER ALL MEDICINES.

(01) YES
(02) NO

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty

SHOW CARD PM1
This card lists some reasons people have given for not having prescriptions filled or refilled.
Which of these reasons explains why [you/(SP)] did not obtain the [READ MEDICINE(S) BELOW]?

SCPMCODS

SC17A

[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

SCPMOTOS

SC17A
BOX SC2

OTHER (SPECIFY)
IF SC17A - SCPMCODS INCLUDES MORE THAN ONE RESPONSE, GO TO SC18A - SCPMMAIN.
ELSE GO TO SC20 - GENERRX.

Which of these was the main reason [you/(SP)] did not obtain [this medicine/these medicines] during
(CURRENT YEAR)?
[READ REASONS BELOW IF NECESSARY.]
SCPMMAIN

SC18A

[MEDICINE 1 FROM SC16]
[MEDICINE 2 FROM SC16]
[MEDICINE 3 FROM SC16]
[MEDICINE 4 FROM SC16]
[MEDICINE 5 FROM SC16]

(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
(05) DIDN'T THINK MEDICINE WAS NECESSARY
(06) NOT COVERED BY INSURANCE/NOT ON PLAN
FORMULARY
(07) TROUBLE OBTAINING MEDICINE
(08) OBTAINED/USED SAMPLES
(09) USED ANOTHER MEDICINE AS A SUBSTITUTION
(91) (OTHER/SC17A - SCPMOTOS OTHER SPECIFY
TEXT)
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]

(01) THOUGHT IT WOULD COST TOO MUCH
(02) DIDN'T THINK MEDICINE WOULD HELP
CONDITION
(03) WAS AFRAID OF MEDICINE
REACTIONS/CONTRAINDICATIONS
(04) DON'T LIKE TO TAKE MEDICINE
(05) DIDN'T THINK MEDICINE WAS NECESSARY
(06) NOT COVERED BY INSURANCE/NOT ON PLAN
FORMULARY
(07) TROUBLE OBTAINING MEDICINE
(08) OBTAINED/USED SAMPLES
(09) USED ANOTHER MEDICINE AS A SUBSTITUTION
(91) (OTHER/SC17A - SCPMOTOS OTHER SPECIFY
TEXT)
(-8) Don't Know
(-9) Refused