CMS-P-0015A Comm2019R84CPQ

Chronic Pain Questionnaire (CPQ)
Variable Name

MR Screen Name

Question type

Question text/description
CHRONIC PAIN QUESTIONNAIRE SPECIFICATIONS

Code list

Routing

CRITERIA
INTTYPE=INTTYPE=C001, C002, C004, C005, C006, C010
SPALIVE=1
SEASON=SUMMER
SPPROXY=SP
Other:
PLACEMENT
Administer after PVQ
SHOW CARD CP1
Now I would like to ask about your experiences with pain.
PAINOFTN

CP1

code one

In the past three months, that is since (TODAY’S MONTH AND YEAR- 3 MONTHS), how often did you have
pain? Would you say never, some days, most days, or every day?

(01) NEVER
(02) SOME DAYS
(03) MOST DAYS
(04) EVERY DAY
(-8) DON’T KNOW
(-9) REFUSED

[READ IF NECESSARY: Please answer based on your usual use of medication.]

SHOW CARD CP2
PAINAMNT

CP2

code one

Thinking about the last time you had pain, how much pain did you have? Would you say a little, a lot, or
somewhere in between?

SHOW CARD CP1
PAINLIMT

CP3

code one

Since (TODAY'S MONTH AND YEAR - 3 MONTHS), how often did your pain limit your life or work activities?
Would you say never, some days, most days, or every day?

SHOW CARD CP1
PAINFAM

CP4

code one

Since (TODAY'S MONTH AND YEAR - 3 MONTH), how often did YOUR pain affect your family and significant
others? Would you say never, some days, most days, or every day?

SHOW CARD CP3
PAINMANG

MANGPHYS

CP5

CP6

code one

list

Since (TODAY'S MONTH AND YEAR - 3 MONTH), to what extent were you able to manage your pain so that
you can do the things you enjoy doing? Would you say not at all, a little, a lot, or somewhere in between?

Since (TODAY'S MONTH AND YEAR - 3 MONTH), did you use any of the following to manage your pain?
Please indicate yes or no to each one.
Physical therapy, rehabilitative therapy, or occupational therapy

(01) A LITTLE
(02) A LOT
(03) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

(01) NEVER
(02) SOME DAYS
(03) MOST DAYS
(04) EVERY DAY
(-8) DON’T KNOW
(-9) REFUSED
(01) NEVER
(02) SOME DAYS
(03) MOST DAYS
(04) EVERY DAY
(-8) DON’T KNOW
(-9) REFUSED

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

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

(01) BOX CPEND
(02) CP2 - PAINAMNT
(03) CP2 - PAINAMNT
(04) CP2 - PAINAMNT
(-8) BOX CPEND
(-9) BOX CPEND

CP3 - PAINLIMT

CP4 - PAINFAM

CP5 - PAINMANG

CP6 - MANGPHYS

CP6- MANGSPNE

MANGSPNE

CP6

list

Spinal manipulation or other forms of chiropractic care

MANGCBT

CP6

list

Talk therapies such as cognitive-behavioral therapy (CBT)

MANGPROG

CP6

list

A chronic pain self-management program or workshop

MANGGROP

CP6

list

Chronic pain peer support groups

MANGYOGA

CP6

list

Yoga, tai chi, or qi gong

MANGMASG

CP6

list

Massage

MANGMEDT

CP6

list

Meditation, guided imagery, or other relaxation techniques
SHOW CARD CP3
Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by...

PAINBACK

CP7

code one
Back pain?
Would you say not at all, a little, a lot, or somewhere in between?
SHOW CARD CP3
[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by...]

PAINARMS

CP8

code one

Pain in your hands, arms, or shoulders?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED
(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

CP6- MANGCBT

CP6 - MANGPROG

CP6 - MANGGROP

CP6- MANGYOGA

CP6- MANGMASG

CP6- MANGMEDT

CP7-PAINBACK

CP8- PAINARMS

CP9 - PAINLEGS

SHOW CARD CP3
[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
PAINLEGS

CP9

code one

Pain in your hips, knees, or feet?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

SHOW CARD CP3
[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
PAINHEAD

CP10

code one
Headache, migraine, or facial pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

CP10 - PAINHEAD

CP11 - PAINABDM

SHOW CARD CP3
[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
PAINABDM

CP11

code one

Abdominal, pelvic, or genital pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

CP12 - PAINTOTH

SHOW CARD CP3
[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
PAINTOTH

CP12

code one

Toothache or jaw pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

BOX CPEND

routing

Go to IAQ.

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

BOX CPEND