CMS-P-0015A Medical Provider Utilzation

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

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

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?
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
SEE SHOWCARD AC1 FOR TYPES OF MEDICAL DOCTORS, IF NECESSARY.
[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) [Continuous answer.]

PROVIDER_MP

MP2

roster

Who did [you/(SP)] see?
SELECT OR ADD ONLY ONE PROVIDER.
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY
ENTERING AN EVENT WITH THAT PROVIDER

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

(01-N) BOX MP1B
(N+1) MP2-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX
MP1B.
ELSE IF "ADD ANOTHER" SELECTED, GO TO MP2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPLCHNGSPL.

[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

GROUP:

BOX MP1B

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND 2. [PROVIDER 2]
…
SELECT "ADD ANOTHER."
N. [PROVIDER N]
ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO
NAME FOR ALL PROVIDERS WHERE
SELECT OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
PROVNUM>02.

CRCTSPL-CRCTSPL

CRCTSPL

verbatim

WHAT IS THE CORRECT SPELLING OF THIS PROVIDER'S NAME?
THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
(01) [Continuous Answer]
SELECT "ADD ANOTHER."
[DISPLAY PROVIDER SELECTED AT CHNGSPL-CHNGSPL]

BOX MP1B

BOX MP1B

routing

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

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CRCTSPL

CHNGSPL

Page 1 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

PROVSPEC

PROVSPOS

MP2A

MP3

BOX MP2

HMOASSOC

HMOREFER

Question Type

MP4

MP5

Question Text/Description

Code List

Routing

(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
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
What kind of (health practitioner/mental health professional/therapist/medical person) is (PROVIDER NAME)?
(17) OSTEOPATH (DO)
(18) PARAMEDIC
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
(42) PHARMACIST
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
(19) PHYSICAL THERAPIST (PT)
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
(20) PHYSICIAN'S ASSISTANT
SPECIALTY NOT LISTED BELOW, BUT LISTED ON SHOWCARD AC1, SUCH AS ‘CARDIOLOGY,’ SELECT
(21) PODIATRIST (FOOT DOCTOR)
'MEDICAL 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) 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

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

(01) [Continuous answer.]

BOX MP1

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.

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

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

MP2A

BOX MP1

VAPLACE

MPQ - MEDICAL PROVIDER UTILIZATION

code 1

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

(01) YES
(02) NO
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
(-8) Don't Know
(-9) Refused

yes/no

[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).]

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

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

MP6 - EVENT

Page 2 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

Code List

Routing

(01) [Continuous answer.]

MP6-MPADD

(01) ADD ANOTHER
(02) ALL DONE

(01) MP6 -EVENT
(02) BOX MP2AA

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

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

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

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

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

[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.

MPADD

MPSDVIS

ANYOPERS

SPECCOND

PRESMDCN

MP6

choose one

BOX MP2AA

routing

HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS 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.

MP6B

yes/no

We have recorded that in (EVENT MONTH) [you were/(SP) was] also in (READ EVENT(S) LISTED BELOW).
Was this visit with (PROVIDER NAME) a visit while [you were/(SP) was] in [the [READ EVENT LISTED
BELOW]/any of these places]?

BOX MP2B

routing

UPDATE EVENT TYPE TO SEPARATELY BILLING DOCTOR AND GO TO BOX MP6A.

BOX MP2C

routing

IF PROVIDER SPECIALTY = Dentist, Medical Doctor, Optometrist, Osteopath, Paramedic, PhysicianAssistant,
Podiatrist, Other, DK or RF, GO TO MP7 - ANYOPERS.
ELSE GO TO MP10 - SPECCOND.

MP7

yes/no

Were any operations or other surgical procedures performed on [you/(SP)] during [any of the/the] [VISIT ON
EVENT DATE]?
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths, or
any cutting of the skin.]

MP10

yes/no

[Was this visit/Were any of these visits] to (PROVIDER NAME) for any specific condition?

BOX MP2D

routing

IF CURRENTLY ADMINISTERING ST, GO TO BOX ST23B.
ELSE IF CURRENTLY ADMINISTERING NS, GO TO BOX NS23B.
ELSE GO TO MP12 - PRESMDCN.

MP12

yes/no

During [this visit/any of these visits] to (PROVIDER NAME), were any medicines prescribed for [you/(SP)]?

Were any of the prescriptions filled?
PRESFILL

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

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

MP13

yes/no

(01) YES
(02) NO
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
(-8) Don't Know
WHEN IT WAS OBTAINED, WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER
(-9) Refused
OR NOT THE RESPONDENT ACTUALLY TOOK THE MEDICINE.]

BOX MP3A

routing

IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT
ROUND, GO TO MP13A - MPPMMEDS.
ELSE GO TO BOX PM2.

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

Page 3 of 10

2019 MCBS Community Questionnaire

Variable Name

MPPMMEDS

MR Screen Name

MP13A

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

no entry

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
information on them.]

Code List

Routing

(01) CONTINUE
(-7) Empty

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 PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM,
AND QUANTITY FOR EACH.

BOX PM3

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).
SAMEFSAM

SAMEFSAM

yes/no

The strength was [MEDICINE STRENGTH].
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 PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

code one

(01) YES
CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
(02) NO
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
(03) NO BUT R CAN ANSWER QUESTIONS
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.
(-9) REFUSED

(01) MED-PMEDNAME
(02) PMKNWNM-PMKNWNM
(03) MED-PMEDNAME
(-8) PMKNWNM-PMKNWNM
(-9) PMKNWNM-PMKNWNM

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 GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.

[MEDICINE NAME SELECTED FROM LOOKUP OR
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]

Page 4 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused

(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD

PMFORMMC

MED

code one

PMFORMOS

MED

verbatim

PMFORMFN

MED

verbatim

[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 OTHER SPECIFY]

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
(-8) Don't Know
(-9) Refused

(01)-(08) MED-MEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID

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

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

[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?

Page 5 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

PMCOND

PMCOND

code one

PMCONDOS

PMCOND

verbatim

Question Text/Description

What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

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

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

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

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

BOX PM6

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

(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
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

[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
PMMORE-PMMORE;
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.

OTHER (SPECIFY)
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 (01) CONTINUOUS ANSWER
IN A DAY 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

Page 6 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

Code List

Routing

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

PM13

(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
(-8) DON'T KNOW
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

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.

yes/no

(01) YES
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of (02) NO
Veterans Affairs or V.A.?
(-8) DON'T KNOW
(-9) REFUSED

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.

PMSATVA

BOX PM8

PMSATHMO

numeric

PMSATHMO

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 NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors
[your/(SP’s)] plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

PMMORE

PM17

BOX MP6AA

MDOCMORE

MP17

yes/no

([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.])
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF
R ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we
haven't talked about?]

PM13 - TABTAKE96

BOX PM7

BOX PM8

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

PMMORE-PMMORE

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX MP6AA

routing

IF ANOTHER MP EVENT WAS ADDED WITH THIS MEDICAL PROVIDER, GO TO BOX MP2AA.
ELSE 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

[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 (01) YES
doctor?
(02) NO
(-8) Don't Know
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT
(-9) Refused
DEPARTMENT OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

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

Page 7 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

BOX MP6A

MPHPRAC

MP18

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

Question Text/Description

routing

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 - MPHPRAC.

yes/no

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, 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.

Code List

Routing

(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

(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

(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

[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

(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 mental health professional
like any of the ones listed on this card? [Mental health professional includes psychiatrist, psychologist, clinical
social worker, and licensed professional counselor.]
[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

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.]

BOX MP7

AFRDMT

MPPRTHER

MP33B

MP34

routing

IF SPALIVE=1 (ALIVE) GO TO MP33B- AFRDMT. ELSE GO TO MP34- MPPRTHER.

yes/no

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?

yes/no

SHOW CARD MP3
(Besides what you have already mentioned), [(Since/since (REFERENCE
DATE/UTILDATE)/(Between/between) (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(01) YES
INSTITUTIONALIZATION/ENDUTILD), [have you/has (SP)/did (SP)] (seen/see) a therapist like any of the ones
(02) NO
listed on this card? [Therapist includes physical therapist, speech therapist, intravenous (IV) therapist,
(-8) Don't Know
massage therapist, occupational therapist, and respiratory therapist.]
(-9) Refused

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

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

Page 8 of 10

2019 MCBS Community Questionnaire

Variable Name

THERMORE

MR Screen Name

MP41

MPQ - MEDICAL PROVIDER UTILIZATION

Question Type

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

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
(-9) Refused
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

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

yes/no

Question Text/Description
[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

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

MPPRMORE

MP56

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 place or any other type of
medical place?
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT
STAYS, OR SENIOR DAY CARE.]

BOX MP8

routing

IF SPALIVE=1 (ALIVE) AND SEASON=FALL GO TO SC11- MCDRNSEE. ELSE GO TO BOX MP22.

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

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

MCDRNSEE

SC11

yes/no

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.]

TEMPCOND1

SC12AA

text

What was the health problem or condition?
ENTER ALL CONDITIONS.

(01) [Continuous answer.]

SC12AA - TEMPCOND2

TEMPCOND2

SC12AA

text

What was the health problem or condition?
ENTER ALL CONDITIONS.

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

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

TEMPCOND3

SC12AA

text

What was the health problem or condition?
ENTER ALL CONDITIONS.

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

SC12A - MCDRATMP

Page 9 of 10

2019 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ - MEDICAL PROVIDER UTILIZATION

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

(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

BOX MP22

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.

SCRCODES

SC13A

code all

Which of these reasons explains why [you/(SP)] did not see a doctor or other health professional about the
[READ CONDITION(S) BELOW]?
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

SCROTOS

SCRMAIN

SC13A

verbatim text

OTHER (SPECIFY)

BOX SC1B

routing

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

SC14A

code 1

BOX MP22

routing

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.]
(CONDITION 1 FROM SC12AA)
(CONDITION 2 FROM SC12AA)
(CONDITION 3 FROM SC12AA)

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

Page 10 of 10