Cms-p-0015a Mcbs

Patient Activation (PAQ)
Variable Name
MR Screen Name
BOX PA1
PAINTRO
PAINTRO

Question type
routing
no entry

PANECESS

PA1

code 1

PASIDEFX

PA2

code 1

PAINSTRC

PA3

code 1

PAMEDREC

PA4

code 1

PACHGDRS

PA5

code 1

PADISAGR

PA6

code 1

PAHCONDS

PA9

code 1

Question text/description
GO TO PAINTRO - PAINTRO.
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.
SHOW CARD PA1
Please tell me how confident you are that you can identify when it is necessary for you to get medical care.

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
SHOW CARD PA1
(01) VERY CONFIDENT
[How confident are you that you can...]
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
Identify when you are having side effects from your medications?
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
SHOW CARD PA1
(01) VERY CONFIDENT
Doctors often give instructions about how you should care for yourself at home, like changing a bandage,
(02) CONFIDENT
taking medicines on schedule, or applying ice packs. How confident are you that you can follow instructions (03) SOMEWHAT CONFIDENT
to care for yourself at home?
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
SHOW CARD PA1
(01) VERY CONFIDENT
Doctors also often give instructions about changing your habits or lifestyle, such as changing your diet,
(02) CONFIDENT
stopping smoking, or getting regular exercise. How confident are you that you can follow this kind of
(03) SOMEWHAT CONFIDENT
instruction, to change your habits or lifestyle?
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
SHOW CARD PA2
(01) VERY LIKELY
Please use this card to respond to the following statements.
(02) LIKELY
(03) UNLIKELY
How likely are you to change doctors if you are dissatisfied with the way you and your doctor communicate? (04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused
SHOW CARD PA2
(01) VERY LIKELY
How likely are you to tell your doctor when you disagree with him or her?
(02) LIKELY
(03) UNLIKELY
(04) VERY UNLIKELY
(-8) Don't Know
(-9) Refused
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

Patient Activation (PAQ)
Variable Name
MR Screen Name
PARXINFO
PA10

Question type
code 1

PADRQUEX

PA11

code 1

PAANSWR

PA12

code 1

PALISTRX

PA13

code 1

PATRSLT

PA14

code 1

PAOPTION

PA15

code 1

PADRLISN

PA16

code 1

PADREXPL

PA20

code 1

Question text/description
SHOW CARD PA3
[Do you always, usually, sometimes, or never...]

Code list
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
Read information about a new prescription, such as side effects and precautions?
(04) NEVER
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
[Do you always, usually, sometimes, or never...]
(02) USUALLY
(03) SOMETIMES
Bring with you to your doctor visits a list of questions or concerns you want to cover?
(04) NEVER
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
[Do you always, usually, sometimes, or never...]
(02) USUALLY
(03) SOMETIMES
Leave your doctor's office feeling that all of your concerns or questions have been fully answered?
(04) NEVER
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
[Do you always, usually, sometimes, or never...]
(02) USUALLY
(03) SOMETIMES
Take a list of all of your prescribed medicines to your doctor visits?
(04) NEVER
(05) NOT APPLICABLE
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
[Do you always, usually, sometimes, or never...]
(02) USUALLY
(03) SOMETIMES
Make sure you understand the results of any medical test or procedure such as an x-ray, blood test, or EKG
(04) NEVER
for heart conditions?
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
[Do you always, usually, sometimes, or never...]
(02) USUALLY
(03) SOMETIMES
Talk with your doctor or other medical person about your options if you need tests, follow-up care, or a
(04) NEVER
referral for care by a medical specialist?
(-8) Don't Know
(-9) Refused
SHOW CARD PA3
(01) ALWAYS
Now I am going to read some statements that may describe your relationship with your doctor. Please tell
(02) USUALLY
me 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
SHOW CARD PA3
(01) ALWAYS
My doctor explains things to me in terms that I can easily understand. Does that always, usually, sometimes, (02) USUALLY
or never happen?
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused

Patient Activation (PAQ)
Variable Name
MR Screen Name
PADVICE
PA21

BOX PA2

Question type
code 1

Question text/description
SHOW CARD PA3
I can call my doctor's office to get medical advice when I need it. Does that always, usually, sometimes, or
never happen?

routing

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Code list
(01) ALWAYS
(02) USUALLY
(03) SOMETIMES
(04) NEVER
(-8) Don't Know
(-9) Refused