CMS-P-0015A Comm2019R83MPQ

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

MEDICAL PROVIDER 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 HHQ.

MPPRMDOC

MP1

yes/no

(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] any medical doctors?
(01) YES
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
(02) NO
SEE SHOWCARD AC1 FOR TYPES OF MEDICAL DOCTORS, IF NECESSARY.
(-8) Don't Know
(-9) Refused
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

(01) MP2 - PROVIDER_MP
(02) MP18 - MPPRPRAC
(-8) MP18 - MPPRPRAC
(-9) MP18 - MPPRPRAC

(01) [Continuous answer.]

PROVIDER_MP

MP2

roster

Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.

[DISPLAY PROVIDER ROSTER AS RESPONSE OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]
N+1. ADD ANOTHER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP NAME
FOR ALL PROVIDERS WHERE PROVNUM>02.

IF EXISTING PROVIDER SELECTED, GO TO
BOX MP1B.
ELSE IF "ADD ANOTHER" SELECTED, GO
TO MP2-PROVNAME

[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
ENTER THE NAME OF THE PROVIDER AND THE BILLING/GROUP OR PRACTICE NAME BELOW.

PROVNAME

MP2

verbatim

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.

MP2-GROUPNAM

YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE PROVIDER
NAME IS ENTERED CORRECTLY.
NAME:
GROUPNAM

MP2
BOX MP1B

routing

GROUP:
IF (PROVIDER IS A MEDICAL PLACE) OR (PROVIDER SPECIALTY HAS ALREADY BEEN COLLECTED), GO TO BOX
MP1.
ELSE GO TO MP2A - PROVSPEC.

BOX MP1B

Variable Name

MR Screen Name

Question type

Question text/description

Code list
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
What kind of (health practitioner/mental health professional/therapist/medical person) is (PROVIDER
(11) I.V. THERAPIST
NAME)?
(12) NURSE (RN)
(13) NURSE PRACTITIONER
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT SPECIFICALLY NAMES (14) NURSE'S AIDE
THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN PARENTHESES FOLLOWING THAT
(15) OCCUPATIONAL THERAPIST (OT)
PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL SPECIALTY NOT LISTED BELOW, BUT LISTED
(16) OPTOMETRIST (OD)
ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT 'MEDICAL DOCTOR.']
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(42) PHARMACIST
(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

Routing

(01) [Continuous answer.]

(01) BOX MP1
(02) BOX MP1
(03) BOX MP1
(04) BOX MP1
(05) BOX MP1
(06) BOX MP1
(07) BOX MP1
(08) BOX MP1
(09) BOX MP1
(10) BOX MP1
(11) BOX MP1
(12) BOX MP1
(13) BOX MP1
(14) BOX MP1
(15) BOX MP1
(16) BOX MP1
(17) BOX MP1
(18) BOX MP1
(19) BOX MP1
(20) BOX MP1
(21) BOX MP1
(22) BOX MP1
(23) BOX MP1
(24) BOX MP1
(25) BOX MP1
(26) BOX MP1
(27) BOX MP1
(28) BOX MP1
(29) BOX MP1
(30) BOX MP1
(31) BOX MP1
(32) BOX MP1
(33) BOX MP1
(34) BOX MP1
(35) BOX MP1
(42) BOX MP1
(91) MP2A - PROVSPOS
(-8) BOX MP1
(-9) BOX MP1
BOX MP1

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP6-EVENT
(02) BOX MP2
(-8) BOX MP2
(-9) BOX MP2

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP6 - EVENT
(02) MP5 - HMOREFER
(-8) MP5 - HMOREFER
(-9) MP5 - HMOREFER

PROVSPEC

MP2A

code 1

PROVSPOS

MP2A

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 MP3 - VAPLACE.
ELSE GO TO BOX MP2.

BOX MP1

VAPLACE

MP3

BOX MP2

HMOASSOC

MP4

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 MP4 - 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 MP5 - HMOREFER.
ELSE GO TO MP6 - EVENT.

yes/no

Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?

Variable Name

MR Screen Name

Question type

HMOREFER

MP5

yes/no

Question text/description
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE RESPONDENT’S PRIMARY CARE PHYSICIAN (PCP).]

Code list
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

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.
EVENT

MP6

roster

Routing
MP6 - EVENT

MP6_IN - NAVIGATOR
(01) [Continuous answer.]
MPADD

[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?
MPADD

MP6

choose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
YOU HAVE ENTERED DATES FOR THE FOLLOWING EVENTS. SELECT AN EVENT TO DISCUSS WITH SP OR PRESS
[PREVIOUS] TO GO BACK AND ADD MORE EVENTS.

NAVIGATOR

MP6_IN

BOX MP2AA

MPSDVIS

instance navigator

routing

MP6B

yes/no

BOX MP2B

routing

BOX MP2C

routing

ANYOPERS

MP7

yes/no

SPECCOND

MP10

yes/no

BOX MP2D

routing

PRESMDCN

PRESFILL

MP12

yes/no

MP13

yes/no

BOX MP3A

routing

[DISPLAY ALL EVENTS ADDED AT ER6]
[EVENT DATE, PROVIDER]
FOR FIRST/NEXT EVENT ENTERED AT MP6, IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND ((EVENT
DATE OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES AN EXISTING ER OR OP EVENT), GO TO
MP6B - MPSDVIS.
ELSE GO TO BOX MP2C.

(01) ADD ANOTHER
(02) ALL DONE

(01) MP6 -EVENT
(02) MP6_IN - NAVIGATOR

(01) ITEM SELECTED IN INSTANCE NAVIGATOR
(02) CONTINUE INTERVIEW SELECTED

(01) BOX MP2AA
(02) BOX MP6AA

(01) YES
We have recorded that in (EVENT MONTH) [you were/(SP) was] also in (READ EVENT(S) LISTED BELOW). Was
(02) NO
this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED BELOW]/any of
(-8) Don't Know
these places]?
(-9) Refused
UPDATE EVENT TYPE TO SEPARATELY BILLING DOCTOR AND GO TO BOX MP6.
IF PROVIDER SPECIALTY = Dentist, Medical Doctor, Optometrist, Osteopath, Paramedic, PhysicianAssistant,
Podiatrist, Other, DK or RF, GO TO MP7 - ANYOPERS.
ELSE GO TO MP10 - SPECCOND.
Were any operations or other surgical procedures performed on [you/(SP)] during [any of the/the] [VISIT ON
(01) YES
EVENT DATE]?
(02) NO
(-8) Don't Know
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths,
(-9) Refused
or any cutting of the skin.]
(01) YES
(02) NO
[Was this visit/Were any of these visits] to (PROVIDER NAME) for any specific condition?
(-8) Don't Know
(-9) Refused
IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO MP12 - PRESMDCN.
(01) YES
(02) NO
During [this visit/any of these visits] to (PROVIDER NAME), were any medicines prescribed for [you/(SP)]?
(-8) Don't Know
(-9) Refused
Were any of the prescriptions filled?
(01) YES
(02) NO
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT, WHEN IT WAS
(-8) Don't Know
OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE
(-9) Refused
RESPONDENT ACTUALLY TOOK THE MEDICINE.]
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND, GO TO
MP13A - MPPMMEDS.
ELSE GO TO BOX PM2.

(01) BOX MP2B
(02) BOX MP2C
(-8) BOX MP2C
(-9) BOX MP2C

(01) BOX MP2D
(02) MP10 - SPECCOND
(-8) MP10 - SPECCOND
(-9) MP10 - SPECCOND

BOX MP2D

(01) MP13 - PRESFILL
(02) BOX MP6
(-8) BOX MP6
(-9) BOX MP6
(01) BOX MP3A
(02) BOX MP6
(-8) BOX MP6
(-9) BOX MP6

Variable Name

MR Screen Name

Question type

MPPMMEDS

MP13A

no entry

Question text/description
Code list
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) CONTINUE
information on them.]
(-7) Empty

Routing

BOX PM2

[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

MEDICINE_PM1

routing

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.

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.

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]

PMEDNAME

MED

lookup

PMBRNAME
PMGNNAME

MED
MED

lookup
lookup

[PRESCRIBED MEDICINE LOOKUP TOOL]
[PM BRAND NAME]
[PM GENERIC NAME]

PMFORMFD

MED

lookup

Medicine Form [FDB LIST FORM NAME]

Variable Name

MR Screen Name

Question type

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

Question text/description

Code list

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 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

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

PMEDID

MED

numeric

FAMILYID

MED

numeric

[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.]

PMKNWNM

PMKNWNM

code one

Medicine strength unit

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

Routing

(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) YES
(02) NO
(-9) REFUSED

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS

(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND

Variable Name

MR Screen Name

Question type

Question text/description

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

GETNUM

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.]

TABNUM

BOX PM5

routing

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.

TABNUM

numeric

HOW MANY PILLS, TABLETS, OR CAPSULES WERE IN THE CONTAINER WHEN IT WAS OBTAINED?

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.]

AMTUNOS

PM16

text

OTHER (SPECIFY)

AMTNUM

PM16

numeric

BOX PM6

routing

IF PRESCRIPTION MEDICINE FORM IS PILLS, TABLETS OR CAPSULES, GO TO PM12 - TABSADAY.
ELSE GO TO BOX PM7.

Code list

Routing

(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)-(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

(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) 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

(01) CONTINUOUS ANSWER

PM16 - AMTNUM

(01) CONTINUOUS ANSWER

BOX PM6

BOX PM6

Variable Name

MR Screen Name

Question type

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

Question text/description
HOW MANY PILLS, TABLETS, OR CAPSULES ARE PRESCRIBED TO BE TAKEN IN A DAY?

Code list

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?

Routing

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

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".

TABTAKE96

PMSATVA

PMSATHMO

PM13

code one

BOX PM7

routing

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

PM13 - TABTAKE96

(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY

BOX PM7

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

BOX PM8

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

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) BOX MP6AA

Variable Name

MR Screen Name

BOX MP6AA

MDOCMORE

MP17

BOX MP6A

MPPRPRAC
MPHPRAC

MP18

Question type

Question text/description

routing

IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP1 PROBE, GO TO MP17 - MDOCMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP18 PROBE, GO TO MP25 - PRACMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP26 PROBE, GO TO MP33 - MENTMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP34 PROBE, GO TO MP41 - THERMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP42 PROBE, GO TO MP49 - PERSMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP50 PROBE, GO TO MP56 - MPPRMORE.

yes/no

routing

yes/no

Code list

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) BOX MP6A
(-8) BOX MP6A
(-9) BOX MP6A

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP26 - MPPRMENT
(-8) MP26 - MPPRMENT
(-9) MP26 - MPPRMENT

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP26 - MPPRMENT
(-8) MP26 - MPPRMENT
(-9) MP26 - MPPRMENT

(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(01) YES
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(02) NO
(SP)/did (SP)] (seen/see) a mental health professional like any of the ones listed on this card? [Mental health
(-8) Don't Know
professional includes psychiatrist, psychologist, clinical social worker, and licensed professional counselor.]
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP34 - MPPRTHER
(-8) MP34 - MPPRTHER
(-9) MP34 - MPPRTHER

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this doctor or any other medical
doctor?
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
IF WINTER ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP REPORTED A MEDICAL
PROVIDER VISIT AT MP6 AND MP6B - MPSDVIS ^= 1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL DOCTOR),
GO TO AC20 - MDSPCLTY.
ELSE GO TO MP18 - MPPRPRAC.
SHOW CARD MP1
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] a health practitioner like any of the ones listed on this card? [Health practitioners
include acupuncturist, audiologist, optometrist, chiropractor, podiatrist (foot doctor), homeopath,
naturopath, or any other kind of health provider who is not a medical doctor.]
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

PRACMORE

MP25

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this practitioner or any other
health practitioner?
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
SHOW CARD MP2

MPPRMENT

MP26

yes/no

[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

MENTMORE

MP33

BOX MP7
AFRDMT

MP33B

yes/no

routing
yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this professional or any other
mental health professional?
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
IF SPALIVE=1 (ALIVE) GO TO MP33B- AFRDMT. ELSE GO TO MP34- MPPRTHER.
Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF
INSTITUTIONALIZATION/ENDUTILD)], was there any time when [you/(SP)] needed mental health care or
counseling, but [you/he/she] didn’t get mental health care because [you/he/she] couldn't afford it?

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) BOX MP7
(-8) BOX MP7
(-9) BOX MP7

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

MP34-MPPRTHER

Variable Name

MPPRTHER

THERMORE

MR Screen Name

MP34

MP41

Code list

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP42 - MPPRPERS.
(-8) MP42 - MPPRPERS
(-9) MP42 - MPPRPERS

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP42 - MPPRPERS
(-8) MP42 - MPPRPERS
(-9) MP42 - MPPRPERS

yes/no

SHOW CARD MP4
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] (seen/see) any other medical persons like the ones listed on this card? [Other medical persons
include nurse, nurse practitioner, paramedic, and physician’s assistant.]
[INCLUDE ANY VISITS FOR TESTS/X-RAYS.
DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.
DO NOT INCLUDE PARAMEDIC IF THE AMBULANCE WAS ONLY USED FOR TRANSPORTATION SERVICES.

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) MP50 - MPPRPLAC
(-8) MP50 - MPPRPLAC
(-9) MP50 - MPPRPLAC

yes/no

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)/ENDUTILD], did [you/(SP)] have any other visits to this person or any other medical (01) YES
person?
(02) NO
(-8) Don't Know
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR CLINIC, AT (-9) Refused
THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

(01) MP2 - PROVIDER_MP
(02) MP50 - MPPRPLAC
(-8) MP50 - MPPRPLAC
(-9) MP50 - MPPRPLAC

Question type

yes/no

yes/no

Question text/description
SHOW CARD MP3
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] (seen/see) a therapist like any of the ones listed on this card? [Therapist includes physical
therapist, speech therapist, intravenous (IV) therapist, massage therapist, occupational therapist, and
respiratory therapist.]
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this therapist or any other
therapist?
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

MPPRPERS

PERSMORE

MPPRPLAC

MP42

MP49

MP50

yes/no

SHOW CARD MP5
(Besides what you have already mentioned), [(Since/since (REFERENCE
DATE/UNTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD), [have you/has (SP)/did (SP)] (visited/visit) any other types of medical
places like the ones listed on this card? [Other types of medical places include health clinic, neighborhood
health center, rural health clinic, infirmary, mental health clinic, urgent care center, or any other place.]

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) BOX MP8
(-8) BOX MP8
(-9) BOX MP8

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) MP2 - PROVIDER_MP
(02) BOX MP8
(-8) BOX MP8
(-9) BOX MP8

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

(01) SC12AA - TEMPCOND1
(02) SC15 - PMNOTGET
(-8) SC15 - PMNOTGET
(-9) SC15 - PMNOTGET

(01) [Continuous answer.]

SC12AA - TEMPCOND2

(01) [Continuous answer.]
(-7) Empty
(01) [Continuous answer.]
(-7) Empty

(01) SC12AA - TEMPCOND3
(-7) SC12A - MCDRATMP

[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR
SENIOR DAY CARE.]

MPPRMORE

MP56

BOX MP8

yes/no

routing

MCDRNSEE

SC11

yes/no

TEMPCOND1

SC12AA

text

TEMPCOND2

SC12AA

text

TEMPCOND3

SC12AA

text

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this place or any other type of
medical place?
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT STAYS, OR
SENIOR DAY CARE.]
IF SPALIVE=1 (ALIVE) AND SEASON=FALL GO TO SC11- MCDRNSEE. ELSE GO TO BOX MP22.
During (CURRENT YEAR), did [you/(SP)] have any health problem or condition about which you think
[you/he/she] should have seen a doctor or other health professional, but did not?
[INCLUDE ALL TYPES OF HEALTH PROBLEMS RANGING FROM MINOR TO SERIOUS ISSUES.]
What was the health problem or condition?
ENTER ALL CONDITIONS.
What was the health problem or condition?
ENTER ALL CONDITIONS.
What was the health problem or condition?
ENTER ALL CONDITIONS.

SC12A - MCDRATMP

Variable Name

MR Screen Name

Question type

Question text/description

Code list

Routing

(01) YES
(02) NO
(-8) Don't Know
(-9) Refused

SC13A - SCRCODES

(01) DIDN'T THINK THE PROBLEM WAS SERIOUS
(02) THOUGHT IT WOULD COST TOO MUCH
(03) TROUBLE FINDING/GETTING TO DOCTOR
(04) TIME/SCHEDULE OR PERSONAL CONFLICTS
(05) THOUGHT DOCTOR COULDN'T DO MUCH ABOUT
PROBLEM
(06) WAS AFRAID OF FINDING OUT WHAT WAS
WRONG
(07) DOCTOR WOULD NOT ACCEPT MY INSURANCE
(91) (OTHER/SC13A - SCROTOS OTHER SPECIFY TEXT)
(-8) Don't Know
(-9) Refused

(01) BOX SC1B
(02) BOX SC1B
(03) BOX SC1B
(04) BOX SC1B
(05) BOX SC1B
(06) BOX SC1B
(07) BOX SC1B
(91) SC13A - SCROTOS
(-8) SC15 - PMNOTGET
(-9) SC15 - PMNOTGET

(01) [Continuous answer.]

BOX SC1B

Did [you/(SP)] attempt to see a doctor or other health professional about this [READ CONDITION(S) BELOW]?

MCDRATMP

SC12A

yes/no

(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
[PROBE: By "attempt" I mean, did [you/(SP)] contact a doctor’s office or other medical place in order to set
an appointment or talk to someone about the condition(s)?]
SHOW CARD MP6
This card lists some reasons people have given for not seeing a doctor or other health professional about a
health problem or condition.
Which of these reasons explains why [you/(SP)] did not see a doctor or other health professional about the
[READ CONDITION(S) BELOW]?

SCRCODES

SC13A

code all
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

SCROTOS

SC13A

verbatim text

BOX SC1B

routing

OTHER (SPECIFY)
IF SC13A - SCRCODES INCLUDES MORE THAN ONE RESPONSE, GO TO SC14A - SCRMAIN.
ELSE GO TO BOX MP22.

Which of these was the main reason [you/(SP)] did not see a doctor or other health professional about (this
condition/these conditions) during (CURRENT YEAR) ?
[READ REASONS BELOW IF NECESSARY.]
SCRMAIN

SC14A

code 1
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)

BOX MP22

routing

If SEASON=WINTER, GO TO ACQ.
If (SEASON=FALL or SUMMER) AND (INTTYPE in (C001, C002, C004,C005, C006, C007,C010), GO TO PMQ.

(01) DIDN'T THINK THE PROBLEM WAS SERIOUS
(02) THOUGHT IT WOULD COST TOO MUCH
(03) TROUBLE FINDING/GETTING TO DOCTOR
(04) TIME/SCHEDULE OR PERSONAL CONFLICTS
(05) THOUGHT DOCTOR COULDN'T DO MUCH ABOUT
PROBLEM
BOX MP22
(06) WAS AFRAID OF FINDING OUT WHAT WAS
WRONG
(07) DOCTOR WOULD NOT ACCEPT MY INSURANCE
(91) (OTHER/SC13A - SCROTOS OTHER SPECIFY TEXT)
(-8) Don't Know
(-9) Refused