Attachment E R79 PAQ revisions (Feb 2017 non-sub change request)

Patient Activation (PAQ)
Variable Name
MR Screen Name

PAINTRO

Question text/description
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.

PAINTRO
Please keep in mind that there are no right or wrong answers to these questions. Your opinions and
experiences are important to us.

PANECESS

PASIDEFX

PA1

PA2

SHOW CARD PA1
Please tell me how confident you are that you can identify when it is necessary for you to get medical care.

SHOW CARD PA1
[How confident are you that you can...]
Identify when you are having side effects from your medications?

PAINSTRC

PAMEDREC

PACHGDRS

PA3

SHOW CARD PA1
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?

PA4

SHOW CARD PA1
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?

PA5

SHOW CARD PA2
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?

PADISAGR

PA6

SHOW CARD PA2
How likely are you to tell your doctor when you disagree with him or her?

Code list
(01) CONTINUE
(-7) Empty
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
(01) VERY LIKELY
(02) LIKELY
(03) UNLIKELY
(04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused
(01) VERY LIKELY
(02) LIKELY
(03) UNLIKELY
(04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused

PAHCONDS

PA9

PARXINFO

PA10

PADRQUEX

PA11

PAANSWR

PA12

PALISTRX

PA13

PATRSLT

PA14

PAOPTION

PA15

SHOW CARD PA3
(01) ALWAYS
These next questions are about practices sometimes associated with receiving medical care. Please tell me if (02) USUALLY
you always, usually, sometimes, or never do the following:
(03) SOMETIMES
(04) NEVER
Do you always, usually, sometimes, or never read about health conditions in newspapers, magazines, or on
(-8) Don't Know
the Internet?
(-9) Refused
(01) ALWAYS
SHOW CARD PA3
(02) USUALLY
[Do you always, usually, sometimes, or never...]
(03) SOMETIMES
(04) NEVER
Read information about a new prescription, such as side effects and precautions?
(-8) Don't Know
(-9) Refused
(01) ALWAYS
SHOW CARD PA3
(02) USUALLY
[Do you always, usually, sometimes, or never...]
(03) SOMETIMES
(04) NEVER
Bring with you to your doctor visits a list of questions or concerns you want to cover?
(-8) Don't Know
(-9) Refused
(01) ALWAYS
SHOW CARD PA3
(02) USUALLY
[Do you always, usually, sometimes, or never...]
(03) SOMETIMES
(04) NEVER
Leave your doctor's office feeling that all of your concerns or questions have been fully answered?
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
SHOW CARD PA3
(03) SOMETIMES
[Do you always, usually, sometimes, or never...]
(04) NEVER
(05) NOT APPLICABLE
Take a list of all of your prescribed medicines to your doctor visits?
(-8) Don't Know
(-9) Refused
(01) ALWAYS
SHOW CARD PA3
(02) USUALLY
[Do you always, usually, sometimes, or never...]
(03) SOMETIMES
(04) NEVER
Make sure you understand the results of any medical test or procedure such as an x-ray, blood test, or EKG for
(-8) Don't Know
heart conditions?
(-9) Refused
(01) ALWAYS
SHOW CARD PA3
(02) USUALLY
[Do you always, usually, sometimes, or never...]
(03) SOMETIMES
(04) NEVER
Talk with your doctor or other medical person about your options if you need tests, follow-up care, or a
(-8) Don't Know
referral for care by a medical specialist?
(-9) Refused

PADRLISN

PA16

PADREXPL

PA20

PADVICE

PA21

SHOW CARD PA3
(01) ALWAYS
Now I am going to read some statements that may describe your relationship with your doctor. Please tell me (02) USUALLY
if the following statements always, usually, sometimes, or never happen.
(03) SOMETIMES
(04) NEVER
My doctor listens to what I have to say about my symptoms and concerns. [Does that always, usually,
(-8) Don't Know
sometimes, or never happen?]
(-9) Refused
(01) ALWAYS
(02) USUALLY
SHOW CARD PA3
(03) SOMETIMES
My doctor explains things to me in terms that I can easily understand. Does that always, usually, sometimes,
(04) NEVER
or never happen?
(-8) Don't Know
(-9) Refused
(01) ALWAYS
(02) USUALLY
SHOW CARD PA3
(03) SOMETIMES
I can call my doctor's office to get medical advice when I need it. Does that always, usually, sometimes, or
(04) NEVER
never happen?
(-8) Don't Know
(-9) Refused