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pdfDental, Vision, and Hearing Care Utilization (DVH)
Variable Name
MR Screen Name
Question type
Question text/description
Code list
Routing
DENTAL, VISION, AND HEARING CARE UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after HIQ.
The next questions are about any medical care [you/(SP)] may have had between (REFERENCE
DATE/UTILDATE) and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD).
DUINT
DUINTRO
no entry
(Now would be a good time to get out the planner that [you/(SP)] may have used to record health care visits
or other medical expenses. We will also refer to any statements you may have received since the last
interview.)
DU1 - DUPROBE
First we’ll talk about dental care.
DUPROBE
PROVIDER_DU
DU1
DU2
yes/no
roster
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or any other person for dental care?
[Dental providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.
(01) DU2 - PROVIDER_DU
(02) DU15 - DVNEED
(03) DO NOT DISPLAY. DATA EDITING
ONLY.
(-8) BOX DU6
(-9) BOX DU6
(01-N) BOX DU1
(N+1) DU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO
BOX DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO
TO DU2-PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU DO
NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP OR
PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
PROVNAME
DU2B
verbatim text
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE PROVIDER
NAME IS ENTERED CORRECTLY.
DU2B - GRPNAME
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
GRPNAME
DU2B
verbatim text
GROUP:
PROVSPEC
PROVSPEC
DU2C
code one
What kind of dental provider is [PROVNAME]?
PROVSPECOTH
DU2C
code one
What kind of dental provider is [PROVNAME]?
PROVSPOS
DU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO DU3 - VAPLACE.
ELSE GO TO BOX DU2.
BOX DU1
VAPLACE
DU3
BOX DU2
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO DU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
HMOASSOC
DU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFER
DU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
EVENT_DU
DU6
roster
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
DUADD
DU6B
chose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(02) MEDICAL DOCTOR
(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) DU2C - PROVSPECOTH
(01) DO NOT DISPLAY
(02) BOX DU2
(01) [Continuous answer.]
BOX DU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX DU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER
DU6 - EVENT_DU
DU6_IN - NAVIGATOR
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
(01) ADD ANOTHER
(02) ALL DONE
DU6B-DUADD
NAVIGATOR
DU6_IN
instance navigator
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) CONTINUE INTERVIEW SELECTED
(N) EVENT N
[DISPLAY ALL EVENTS ADDED AT DU6]
(N+1) CONTINUE INTERVIEW
[EVENT DATE, PROVIDER]
SHOW CARD DU1 DVH1
DVPROCDR
DU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
DU7A
verbatim text
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
PRESMDCN
DU9
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
PRESFILL
DUPMMEDS
DU10
yes/no
BOX DU3B
routing
DU10A
no entry
BOX PM2
routing
(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(95) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN
(01) [CONTINUOUS ANSWER]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
DU9 - PRESMDCN
(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, 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
DU10A - DUPMMEDS.
ELSE GO TO BOX 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
(01) INSTRUCTION WAS READ
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO TO
MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
(01) DU7 - DVPROCDR
(02) DU14 - DUMORE
BOX PM2
MEDICINE_PM1
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM, STRENGTH
AND AMOUNT ARE EXACTLY 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 was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6A-GETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE
FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE LOOKUP
BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT, USE THE
[MEDICINE NAME SELECTED FROM LOOKUP OR
GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
STRNNUMBB
MED
numeric
Medicine strength number
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
Medicine Form [MCBS FORM]
Medicine strength unit
(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
(01)-(12) MED-PMSTRNFD
(07) SHAMPOO, SOAP
(91) MED-PMFORMOS
(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) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(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
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY, EXCLUDING
STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
numeric
BOX PM5
routing
TABNUM
numeric
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
BOX PM6
routing
TABSADAY
PM12
numeric
[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 GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO PMMOREPMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS ("PILL",
"TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
OTHER (SPECIFY)
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(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
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
BOX PM5
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
PM16 - AMTNUM
BOX PM6
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A DAY (01) CONTINUOUS ANSWER
AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
PM12 - TABSADAY95
TABSADAY95
PM12
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
code one
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PM13
PM13
BOX PM7
PMSATVA
PMSATVA
BOX PM8
PMSATHMO
PMSATHMO
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
code one
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department
of Veterans Affairs or V.A.?
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
yes/no
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
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-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.])
PMMORE
DUMORE
DVNEED
PM17
yes/no
DU14
yes/no
BOX DU5
routing
DU15
yes/no
(01) ADD ANOTHER
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R ALREADY (02) ALL DONE
INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't talked
about?]
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other dental care visits to this or any other
(-8) Don't Know
provider?
(-9) Refused
IF SPALIVE=1 (ALIVE) GO TO DU15-DVNEED. ELSE GO TO BOX DU6.
(01) YES
(02) NO
Since (REFERENCE DATE), was there a time when {you/SP} needed dental care but could not get it at that
(-8) Don't Know
time?
(-9) Refused
(01) BOX PM2
(02) DU_14 - DUMORE
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(-8) BOX DU5
(-9) BOX DU5
(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT DOING
IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO AWAY
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(95) DU16A - DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6
(01) continuous answer
BOX DU6
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to an eye doctor or any other person for eye care?
[Eye care providers include ophthalmologists, optometrists, and opticians.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(03) DO NOT DISPLAY. DATA EDITING
ONLY.
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.
DVNDRS
DU16
code all
What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?
DVNDRSOS
DU16A
BOX DU6
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO NEXT SECTION VU1-VUPROBE.
VUPROBE
PROVIDER_VU
VU1
VU2
yes/no
roster
(01-N) BOX VU1
(N+1) VU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO
BOX VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO
TO VU2-PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU DO
NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP OR
PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
VPRVNAME
VU2B
verbatim text
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE PROVIDER
NAME IS ENTERED CORRECTLY.
VU2B - GRPNAME
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
VGRPNAME
PROVSPEC
VU2B
VU2C
verbatim text
code one
GROUP:
What kind of eye care provider is [PROVNAME]?
PROVSPEC
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(42) OPTICIAN
(09) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX VU2
(16) BOX VU2
(42) BOX VU2
(09) VU2C - PROVSPECOTH
(-8) BOX VU2
(-9) BOX VU2
PROVSPECOTH
VU2C
code one
What kind of eye care provider is [PROVNAME]?
PROVSPOS
VU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
BOX VU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO VU3 - VAPLACE.
ELSE GO TO BOX VU2.
VAPLACE
VU3
BOX VU2
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO VU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO VU5 - HMOREFER.
ELSE GO TO VU6 - EVENT_VU.
HMOASSC
VU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFR
VU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX VU2
(02) DO NOT DISPLAY
(03) BOX VU2
(04) BOX VU2
(05) BOX VU2
(06) BOX VU2
(07) BOX VU2
(08) BOX VU2
(09) BOX VU2
(10) BOX VU2
(11) BOX VU2
(12) BOX VU2
(13) BOX VU2
(14) BOX VU2
(15) BOX VU2
(16) DO NOT DISPLAY
(17) BOX VU2
(18) BOX VU2
(19) BOX VU2
(20) BOX VU2
(21) BOX VU2
(22) BOX VU2
(23) BOX VU2
(24) BOX VU2
(25) BOX VU2
(26) BOX VU2
(27) BOX VU2
(28) BOX VU2
(29) BOX VU2
(30) BOX VU2
(31) BOX VU2
(32) BOX VU2
(33) BOX VU2
(34) BOX VU2
(91) VU2D - PROVSPOS
(-8) BOX VU2
(-9) BOX VU2
BOX VU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX VU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER
VU6 - EVENT_VU
EVENT_VU
VU6
roster
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
VUADD
NAVIGATOR
VU6B
VU6_IN
chose one
instance navigator
VUPROCDR
VU7
code all
EVOSTEXT
VU7A
verbatim text
PRESMDCN
VU9
yes/no
PRESFILL
VU10
yes/no
BOX VU3B
routing
VU10A
no entry
VUPMMEDS
routing
VU6_IN - NAVIGATOR
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) CONTINUE INTERVIEW SELECTED
(N) EVENT N
[DISPLAY ALL EVENTS ADDED AT VU6]
(N+1) CONTINUE INTERVIEW
[EVENT DATE, PROVIDER]
(01) EYE OR VISION EXAM
(02) CONTACT LENS FITTING
(03) CONTACT LENS PURCHASE
(04) EYE GLASS FRAME FITTING OR ADJUSTMENT
(05) EYE GLASS PURCHASE
(06) REFRACTIVE SURGERY (CORRECTIVE VISION
SURGERY)
SHOW CARD DVH2
(07) CATARACT SURGERY
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
(08) GLAUCOMA SURGERY
(09) CORNEAL SURGERY
CHECK ALL THAT APPLY.
(10) VITREO-RETINAL SURGERY
(11) OCULOPLASTIC SURGERY
(12) EYE MUSCLE SURGERY
(13) EYE REMOVAL
(95) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
(01) YES
(02) NO
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(-8) Don't Know
(-9) Refused
Were any of the prescriptions filled?
(01) YES
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHETHER OR (02) NO
NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE
(-8) Don't Know
MEDICINE.]
(-9) Refused
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
VU10A - VUPMMEDS.
ELSE GO TO BOX 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
(01) INSTRUCTION WAS READ
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
(01) continuous answer
(-8) Don't Know
(-9) Refused
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO TO
MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
VU6B-VUADD
(01) VU6 -EVENT_VU
(02) VU6_IN - NAVIGATOR
(01) VU7 - VUPROCDR
(02) VU14 - VUMORE
(01) VU9-PRESMDCN
(02) VU9-PRESMDCN
(03) VU9-PRESMDCN
(04) VU9-PRESMDCN
(05) VU9-PRESMDCN
(06) VU9-PRESMDCN
(07) VU9-PRESMDCN
(08) VU9-PRESMDCN
(09) VU9-PRESMDCN
(10) VU9-PRESMDCN
(11) VU9-PRESMDCN
(12) VU9-PRESMDCN
(13) VU9-PRESMDCN
(95) VU7A-EVOSTEXT
(-8) VU9-PRESMDCN
(-9) VU9-PRESMDCN
VU9 - PRESMDCN
(01) VU10 - PRESFILL
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
(01) BOX VU3B
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
BOX PM2
MEDICINE_PM1
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM, STRENGTH
AND AMOUNT ARE EXACTLY 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 was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6A-GETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE
FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE LOOKUP
BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT, USE THE
[MEDICINE NAME SELECTED FROM LOOKUP OR
GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
MED
MED
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
PMFMCODE
MED
lookup
Medicine Form [FDB LIST FORM CODE]
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
Medicine Form [MCBS FORM]
(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
(01)-(12) MED-PMSTRNFD
(07) SHAMPOO, SOAP
(91) MED-PMFORMOS
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
Medicine strength unit
(01) CONTINUOUS ANSWER
(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
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY, EXCLUDING
STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
routing
TABNUM
numeric
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
numeric
BOX PM5
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-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 GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO PMMOREPMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS ("PILL",
"TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(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
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A DAY (01) CONTINUOUS ANSWER
AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
PM12 - TABSADAY95
PM13-TABTAKE
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PMSATVA
PMSATHMO
PM13
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
PMSATVA
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department
of Veterans Affairs or V.A.?
BOX PM8
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
yes/no
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
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
PMSATHMO
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
PMMORE-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.])
PMMORE
PM17
yes/no
(01) ADD ANOTHER
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R ALREADY (02) ALL DONE
INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't talked
about?]
(01) BOX PM2
(02) VU_14 - VUMORE
VUMORE
VU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other eye care visits to this or any other
provider?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) OM2 - EVENT_OMEYEG OM1BVUTYPE
(02) OM3 - OMPRHEAR BOX VU5
(03) DO NOT DISPLAY.
(-8) OM3 - OMPRHEAR BOX VU5
(-9) OM3 - OMPRHEAR BOX VU5
(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED
OM2-EVENT_OMEYEG
Next I’m going to ask you about other medical expenses related to vision care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
OMPREYEG
OM1
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
replace, or pay for repairs of eyeglasses or contact lenses?
[Please include the purchases you made during the visit(s) to eye care providers on (EVENT DATES) that you
just told me about.]
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
VUTYPE
OM1B
code all
What did you buy or repair?
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
EVENT_OMEYEG
OM2
roster
Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
HAVE ALL DATES BEEN ENTERED?
OMADD
NAVIGATOR
OM2AA
code one
BOX OM1AA
routing
OM2_IN
instance navigator
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM2_IN - NAVIGATOR.
ELSE GO TO BOX OM1AA2.
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO
VUNEED
OM2A
yes/no
BOX OM1AA1
routing
BOX OM1AA2
routing
BOX VU5
routing
VU15
yes/no
[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician,
optometrist or other place that honors [your/(SP’s)] plan card; or through a place or service that the plan
referred [you/(SP)] to.]
(01) continuous answer
(-8) Don't Know
(-9) Refused
BOX OM1AA
MM:
DD:
YYYY:
(01) ADD ANOTHER
(02) ALL DONE
(01) OM2-EVENT_OMEYEG
(02) BOX OM1AA
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) OM2A - OMSATHMO
(02) BOX OM1AA2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX OM1AA1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU16 - VUVNDRS
(02) BOX VU6
(-8) BOX VU6
(-9) BOX VU6
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
GO TO OM2_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO OM3 - OMPRHEAR BOX VU5.
IF SPALIVE=1 (ALIVE) GO TO VU15-VUNEED. ELSE GO TO BOX VU6.
Since (REFERENCE DATE), was there a time when {you/SP} needed vision care but could not get it at that
time?
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT DOING
IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX VU6
(02) BOX VU6
(03) BOX VU6
(04) BOX VU6
(05) BOX VU6
(06) BOX VU6
(07) BOX VU6
(08) BOX VU6
(09) BOX VU6
(10) BOX VU6
(95) VU16A - VUVNDRSOS
(-8) BOX VU6
(-9) BOX VU6
(01) continuous answer
BOX VU6
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care?
[Hearing care providers include otorhinolaryngologists (ear nose and throat doctors), otologists,
neurotologists, audiologists, audiometrists, and hearing instrument specialists.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) HU2 - PROVIDER_HU
(02) OM3-OMPRHEAR
(03) DO NOT DISPLAY. DATA EDITING
ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR
Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
(01-N) LIST ALL PROVIDERS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.
VUVNDRS
VU16
code all
What were the reasons that {you/SP} could not get the vision care {you/she/he} needed?
VUVNDRSOS
VU16A
BOX VU6
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO HU1-HUPROBE
HUPROBE
PROVIDER_HU
HU1
HU2
yes/no
roster
(01-N) BOX HU1
(N+1) HU2B-PROVNAME
IF EXISTING PROVIDER SELECTED, GO TO
BOX HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO
TO HU2-PROVNAME
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT YOU DO
NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE GROUP OR
PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.
HPRVNAME
HU2B
verbatim text
HU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE PROVIDER
NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
HGRPNAM
HPRVSPEC
HU2B
HU2C
verbatim text
code one
NAME:
GROUP:
What kind of hearing care provider is [PROVNAME]?
PROVSPEC
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(43) AUDIOMETRIST
(44) HEARING INSTRUMENT SPECIALIST
(09) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX HU2
(03) BOX HU2
(43) BOX HU2
(44) BOX HU2
(09) HU2C - PROVSPECOTH
(-8) BOX HU2
(-9) BOX HU2
PROVSPECOTH
HU2C
code one
What kind of hearing care provider is [PROVNAME]?
PROVSPOS
HU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
BOX HU1
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO HU3 - VAPLACE.
ELSE GO TO BOX HU2.
VAPLACE
HU3
BOX HU2
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HU4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO HU5 - HMOREFER.
ELSE GO TO HU6 - EVENT_HU.
HMOASSC
HU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFR
HU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34) LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX HU2
(02) DO NOT DISPLAY
(03) DO NOT DISPLAY
(04) BOX HU2
(05) BOX HU2
(06) BOX HU2
(07) BOX HU2
(08) BOX HU2
(09) BOX HU2
(10) BOX HU2
(11) BOX HU2
(12) BOX HU2
(13) BOX HU2
(14) BOX HU2
(15) BOX HU2
(16) BOX HU2
(17) BOX HU2
(18) BOX HU2
(19) BOX HU2
(20) BOX HU2
(21) BOX HU2
(22) BOX HU2
(23) BOX HU2
(24) BOX HU2
(25) BOX HU2
(26) BOX HU2
(27) BOX HU2
(28) BOX HU2
(29) BOX HU2
(30) BOX HU2
(31) BOX HU2
(32) BOX HU2
(33) BOX HU2
(34) BOX HU2
(91) HU2D - PROVSPOS
(-8) BOX HU2
(-9) BOX HU2
BOX HU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER
HU6 - EVENT_HU
EVENT_HU
HU6
roster
When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/(UTILDATE))/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT VISITS"
AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?
HUADD
NAVIGATOR
HU6B
HU6_IN
chose one
instance navigator
HVPROCDR
HU7
code all
EVOSTEXT
HU7A
verbatim text
PRESMDCN
HU9
yes/no
PRESFILL
HU10
yes/no
BOX HU3B
routing
HU10A
no entry
HUPMMEDS
routing
HU6_IN - NAVIGATOR
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE, GO TO
MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.
HU6B-HUADD
(01) ADD ANOTHER
(02) ALL DONE
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.
(02) CONTINUE INTERVIEW SELECTED
(N) EVENT N
[DISPLAY ALL EVENTS ADDED AT HU6]
(N+1) CONTINUE INTERVIEW
[EVENT DATE, PROVIDER]
(01) HEARING AID FITTING/EVALUATION
(02) HEARING AID PURCHASE/REPAIR
(03) HEARING EXAM
(04) EAR WAX REMOVAL
SHOW CARD DVH3
(05) EAR VENTILATION TUBES
(06) TYMPANOPLASTY (RECONSTRUCTION OF EAR
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
DRUM)
(07) COCHLEAR IMPLANT SURGERY
CHECK ALL THAT APPLY.
(08) HEARING REHABILITATIVE SERVICES
(95) OTHER
(-8) DON'T KNOW
(-9) REFUSED
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
(01) YES
(02) NO
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(-8) Don't Know
(-9) Refused
Were any of the prescriptions filled?
(01) YES
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHETHER OR (02) NO
NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT ACTUALLY TOOK THE
(-8) Don't Know
(-9) Refused
MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
HU10A - HUPMMEDS.
ELSE GO TO BOX 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
(01) INSTRUCTION WAS READ
information on them.]
[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.
BOX PM2
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) HU7 - DVPROCDR
(02) HU14 - HUMORE
(01) HU9-PRESMDCN
(02) HU9-PRESMDCN
(03) HU9-PRESMDCN
(04) HU9-PRESMDCN
(05) HU9-PRESMDCN
(06) HU9-PRESMDCN
(07) HU9-PRESMDCN
(95) HU7A-EVOSTEXT
(-8) HU9-PRESMDCN
(-9) HU9-PRESMDCN
HU9 - PRESMDCN
(01) HU10 - PRESFILL
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
(01) BOX HU3B
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
BOX PM2
MEDICINE_PM1
MEDICINE_PM1
code one
What is the name of the medicine?
BOX PM3
routing
IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME AND STRENGTH FOR EACH.
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM, STRENGTH
AND AMOUNT ARE EXACTLY 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 was [MEDICINE STRENGTH].
SAMEFSAM
SAMEFSAM
yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6A-GETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS ABOUT THE
FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE LOOKUP
BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT, USE THE
[MEDICINE NAME SELECTED FROM LOOKUP OR
GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
MED
MED
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
PMFORMFD
MED
lookup
Medicine Form [FDB LIST FORM NAME]
PMFMCODE
MED
lookup
Medicine Form [FDB LIST FORM CODE]
(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
lookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
Medicine Form [MCBS FORM]
(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
(01)-(12) MED-PMSTRNFD
(07) SHAMPOO, SOAP
(91) MED-PMFORMOS
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
Medicine strength unit
(01) CONTINUOUS ANSWER
(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
(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY, EXCLUDING
STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
What condition is this medicine prescribed for or what is its primary use?
PMCOND
PMCOND
code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
PMCONDOS
PMCOND
verbatim
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM
TABNUM
GETNUM
routing
TABNUM
numeric
(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused
BOX PM5
HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
BOX PM6
(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6
numeric
BOX PM5
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-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 GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO PMMOREPMMORE;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS ("PILL",
"TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTNUM.
AMTUNIT
PM16
quantity unit
HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]
(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
AMTUNOS
PM16
text
OTHER (SPECIFY)
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
AMTNUM
PM16
numeric
(01) CONTINUOUS ANSWER
BOX PM6
BOX PM6
routing
IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?
TABSADAY
PM12
numeric
TABSADAY95
PM12
code one
IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A DAY (01) CONTINUOUS ANSWER
AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty
How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
PM12 - TABSADAY95
PM13-TABTAKE
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often
the medicine is prescribed to be taken.]
TABTAKE
TABTAKE96
PM13
PM13
BOX PM7
PMSATVA
PMSATVA
BOX PM8
PMSATHMO
PMSATHMO
numeric
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
code one
routing
(01) CONTINUOUS ANSWER
(-7) EMPTY
(-8) DON'T KNOW
PM13 - TABTAKE96
BOX PM7
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department
of Veterans Affairs or V.A.?
routing
IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.
yes/no
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
(01) YES
NAME(S) BELOW]?
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
(-9) REFUSED
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
BOX PM8
PMMORE-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.])
PMMORE
PM17
yes/no
(01) ADD ANOTHER
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R ALREADY (02) ALL DONE
INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't talked
about?]
(01) BOX PM2
(02) HU_14 - HUMORE
HUMORE
HU14
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have hearing care visits to this or any other provider?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU2 - PROVIDER_HU
(02) OM3-OMPRHEAR
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) HU16-INNEREAR
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9
(01) LEFT EAR
(02) RIGHT EAR
HU16-OUTREAR
Next I’m going to ask you about other medical expenses related to hearing care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
OMHEARAD
HU15
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
replace, or pay for repairs of a hearing aid?
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that
you just told me about.]
[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN THE OMQ
AS A HEARING/SPEECH DEVICE.]
What type of hearing aid(s) did you purchase?
[IF NEEDED: Were they for your left ear, right ear, or both?]
INNEREAR
HU16
list
CHECK ALL THAT APPLY
Inner ear hearing aid
OUTREAR
HU16
list
Outer ear hearing aid
OVEREAR
HU16
list
Over ear hearing aid
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?
EVENT_OMHRAD HU17
roster
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
HAVE ALL DATES BEEN ENTERED?
OMADD
NAVIGATOR
HU18
code one
BOX HU6
routing
HU18_IN
instance navigator
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO HU18_IN - NAVIGATOR.
ELSE GO TO BOX HU8.
(01) LEFT EAR
(02) RIGHT EAR
(01) LEFT EAR
(02) RIGHT EAR
(01) continuous answer
(-8) Don't Know
(-9) Refused
HU16-OVREAR
HU17-EVENT_OMHRAD
MM:
DD:
YYYY:
HU18-OMADD
(01) ADD ANOTHER
(02) ALL DONE
(01) HU17-EVENT_OMHRAD
(02) BOX HU6
(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED
(01) HU19- OMSATHMO
(02) BOX HU8
On (EVENT DATE), did [you/(SP)] buy or repair the hearing aid at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
OMSATHMO
HVNEED
HU19
yes/no
BOX HU7
routing
BOX HU8
routing
BOX HU9
routing
HU20
yes/no
(01) YES
(02) NO
[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other (-8) Don't Know
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)]
(-9) Refused
to.]
BOX HU7
GO TO HU18_IN - NAVIGATOR.
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.
IF SPALIVE=1 (ALIVE) HU20-HVNEED. ELSE GO TO BOX HU10.
Since (REFERENCE DATE), was there a time when {you/SP} needed hearing care but could not get it at that
time?
HVNDRS
HU21
code all
What were the reasons that {you/SP} could not get the hearing care {you/she/he} needed?
HVNDRSOS
HU21A
BOX HU10
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO EMERGENCY UTILIZATION (ERQ).
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT DOING
IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(95) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(01) HU21- HVNDRS
(02) BOX HU10
(-8) BOX HU10
(-9) BOX HU10
(01) BOX HU10
(02) BOX HU10
(03) BOX HU10
(04) BOX HU10
(05) BOX HU10
(06) BOX HU10
(07) BOX HU10
(08) BOX HU10
(09) BOX HU10
(10) BOX HU10
(95) HU16A - HVNDRSOS
(-8) BOX HU10
(-9) BOX HU10
BOX HU10
| File Type | application/pdf |
| Author | Andrea Mayfield |
| File Modified | 2018-05-03 |
| File Created | 2018-05-03 |