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pdfMCBS Nonsubstantive Change Request Fall 2020 Round 88
Variable Name
MR Screen Name
Question type
Revised HFQ- Health Status and Functioning
Question text/description
Code list
Routing
(01) excellent,
(02) very good,
(03) good,
(04) fair, or
(05) poor?
(-8) DON'T KNOW
(-9) REFUSED
HFA2 - COMPHLTH
(01) much better now than one year ago,
(02) somewhat better now than one year ago,
(03) about the same,
(04) somewhat worse now than one year ago, or
(05) much worse now than one year ago?
(-8) DON'T KNOW
(-9) REFUSED
HFA2B - FUTRHLTH
HEALTH STATUS AND FUNCTIONING QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006
SPALIVE=1
SEASON=FALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in(C001, C002, C003, C004, C005, C006), administer after PVQ.
BOX HFBEG
GENHELTH
HFA1
routing
code one
GO TO HFA1 - GENHELTH
In general, compared to other people [your/(SP's)] age, would you say that [your/his/her] health is . . .
SHOW CARD HF1
COMPHLTH
HFA2
code one
Compared to one year ago, how would you rate [your/(SP's)] health in general now?
Would you say [your/(SP's)] health is . . .
SHOW CARD HF2
FUTRHLTH
HFA2B
code one
In the next 6 months, what do you think will happen to [your/(SP's)] overall health?
Now, I would like to ask you about [your/(SP's)] health.
DISHEAR
DIS1
yes/no
[Are you/Is (SP)] deaf or [do you/does (SP)] have serious difficulty hearing?
DISSEE
DIS2
yes/no
[Are you/Is (SP)] blind or [do you/does (SP)] have serious difficulty seeing, even when wearing glasses?
DISDECISION
DIS3
yes/no
Because of a physical, mental, or emotional condition, [do you/does (SP)] have serious difficulty concentrating,
remembering, or making decisions?
DISWALK
DIS4
yes/no
[Do you/Does (SP)] have serious difficulty walking or climbing stairs?
DISBATH
DIS5
yes/no
[Do you/Does (SP)] have difficulty dressing or bathing?
DISERRANDS
DIS6
yes/no
Because of a physical, mental, or emotional condition, [do you/does (SP)] have difficulty doing errands alone
such as visiting a doctor's office or shopping?
(01) it will get much better
(02) it will get somewhat better
(03) it will not change
(04) it will get somewhat worse
(05) it will get much worse
(-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
DIS1 - DISHEAR
DIS2 - DISSEE
DIS3 - DISDECISION
DIS4 - DISWALK
DIS5 - DISBATH
DIS6 - DISERRANDS
HFA3 - HELMTACT
Page 1 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
HELMTACT
HFA3
code one
Revised HFQ- Health Status and Functioning
How much of the time during the past month has [your/(SP's)] health limited [your/(SP's)] social activities, like
visiting with friends or close relatives?
Would you say . . .
Next we are going to ask some questions about [your/(SP's)] vision and hearing.
ECHELP
HFB1
yes/no
[Do you/Does (SP)] wear eyeglasses or contact lenses?
ECTROUB
HFB2
code one
ECLEGBLI
HFB2A
yes/no
Which statement best describes [your/(SP's)] vision [while wearing glasses or contact lenses]... no trouble
seeing, a little trouble, a lot of trouble, or no usable vision?
[Have you/Has (SP)] been told that [you are/he is/she is] legally blind?
[EXPLAIN IF NECESSARY: Informally, a person is legally blind when, even with corrective lenses, they cannot see
well enough to drive.]
(01) none of the time,
(02) some of the time,
(03) most of the time, or
(04) all of the time?
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(03) SP IS BLIND
(-8) DON'T KNOW
(-9) REFUSED
(01) NO TROUBLE SEEING
(02) A LITTLE TROUBLE SEEING
(03) A LOT OF TROUBLE SEEING
(04) NO USABLE VISION
(-8) DON'T KNOW
(-9) REFUSED
HFB1-ECHELP
(01) HFB2 - ECTROUB
(02) HFB2 - ECTROUB
(03) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM
(01) HFB6 - EDOCEXAM
(02) HFB6 - EDOCEXAM
(03) HFB2A - ECLEGBLI
(04) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HFB6 - EDOCEXAM
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
(01) HFB7A - EDOCTYPE
(02) BOX HFC
(-8) BOX HFB1
(-9) BOX HFB1
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
(996) BOX HFB1
(01) - (12) HFB7A - EDOCTYPE
(-8) BOX HFB1
(-9) BOX HFB1
(01) OPTOMETRIST
(02) OPHTHALMOLOGIST
(91) OTHER DOCTOR SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01) H7B7B - EDOCDLAT
(02) H7B7B - EDOCDLAT
(91) HFB7 - EDOCTYOS
(-8) BOX HFB1
(-9) BOX HFB1
[Have you/Has (SP)] had an eye examination by an eye doctor since (LAST HF MONTH YEAR)?
EDOCEXAM
HFB6
yes/no
INCLUDE OPHTHALMOLOGISTS AND OPTOMETRISTS.
[IF NEEDED: Please include any eye exams that took place during a visit that you may have already told me
about.]
BOX HFC
EDOCLAST
HFB7
routing
code one
IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFB7-EDOCLAST.
ELSE GO TO BOX HFB1.
How long has it been since [your/(SP's)] last eye examination by an eye doctor ?
I have a couple of questions about [your/(SP’s)] last eye examination.
EDOCTYPE
HFB7A
code one
Was the eye examination given by an optometrist, ophthalmologist or some other type of doctor or eye care
professional?
[EXPLAIN IF NECESSARY: An optometrist is a doctor of optometry (O.D.) who diagnoses and treats visual health
problems. An ophthalmologist is a doctor of medicine (M.D.) who specializes in surgery and diseases of the eye.]
EDOCTYOS
HFB7A
verbatim text
OTHER (SPECIFY)
H7B7B - EDOCDLAT
Page 2 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
Again, thinking about [your/(SP’s)] last eye examination, were dilating drops used in [your/(SP)’s] eyes?
EDOCDLAT
HFB7B
yes/no
[EXPLAIN IF NECESSARY: Dilating drops are used to enlarge the pupil for eye examinations. The drops often
make your eyes more sensitive to bright light and may cause temporary blurry vision.]
I am going to read a list of eye conditions. Please tell me if [you have/(SP) has] ever been told by a doctor or
other health professional that [you/he/she] had any of these conditions.
ECATARAC
HFB7C
yes/no
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HFB7C - ECATARAC
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HFB7C - EGLAUCOM
Cataracts?
EGLAUCOM
HFB7C
yes/no
Glaucoma?
ERETINOP
HFB7C
yes/no
Diabetic retinopathy?
EMACULAR
HFB7C
yes/no
Macular degeneration or age-related macular degeneration, also called AMD?
BOX HFB1A
routing
IF ECATARAC=02/NO, GO TO BOX HFB1. ELSE GO TO HFB10 - ECCATOP.
HFB10
yes/no
[Have you/Has (SP)] ever had an operation for cataracts?
BOX HFB1
routing
IF HFB7C - ERETINOP = 1/Yes OR HFB7C - EMACULAR = 1/Yes, GO TO HFB11 - ELASRSUR.
ELSE GO TO HFC1 - HCHELP.
ECCATOP
Laser surgery to the back of the eye, or retina, is a commonly used treatment for diabetic retinopathy and
macular degeneration.
ELASRSUR
HFB11
yes/no
[Have you/Has (SP)] ever had laser surgery to the back of either eye for one of these conditions?
(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
HFB7C - ERETINOP
HFB7C - EMACULAR
BOX HFB1A
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX HFB1
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
HFC1 - HCHELP
(01) YES
(02) NO
(03) SP IS DEAF
(-8) DON'T KNOW
(-9) REFUSED
(01) NO TROUBLE HEARING
(02) A LITTLE TROUBLE HEARING
(03) A LOT OF TROUBLE HEARING
(04) DEAF
(-8) DON'T KNOW
(-9) REFUSED
(01) HFC2 - HCTROUB
(02) HFC2 - HCTROUB
(03) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL
(01) HFD1A - FOODTRBL
(02) HFC3 - HCKNOWMC
(03) HFC3 - HCKNOWMC
(04) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL
(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED
HFC4 - HCCOMDOC
[EXPLAIN IF NECESSARY: This does not include "Lasik" surgery to the front of the eye used to correct vision.]
HCHELP
HFC1
yes/no
[Do you/Does (SP)] use a hearing aid?
HCTROUB
HFC2
code one
Which statement best describes [your/(SP's)] hearing [with a hearing aid]: no trouble hearing, a little trouble, a
lot of trouble, or deaf?
code one
How much trouble [do you/does (SP)] have finding out things [you need/he needs/she needs] to know about
Medicare because [of (your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would you say [you
have/she has/he has] no trouble, a little trouble, or a lot of trouble?
HCKNOWMC
HFC3
Page 3 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
HCCOMDOC
HFC4
code one
FOODTRBL
HFD1A
code one
HEIGHTFT
HFE1
numeric
HEIGHTIN
HFE1
numeric
WEIGHT
HFE1
numeric
Revised HFQ- Health Status and Functioning
(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED
(01) NO TROUBLE
(02) A LITTLE TROUBLE
How much trouble [do you/does (SP)] have eating solid foods because of problems with [your/his/her] mouth or
(03) A LOT OF TROUBLE
teeth? Would you say [you have/she has/he has] no trouble, a little trouble, or a lot of trouble?
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
How tall [are you/is (SP)]?
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
How tall [are you/is (SP)]?
(-8) DON'T KNOW
(-9) REFUSED
How much trouble [do you/does (SP)] have communicating with [your/his/her] doctor or other health
professional because [of (your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would you say [you
have/she has/he has] no trouble, a little trouble, or a lot of trouble?
How much [do you/does (SP)] weigh?
[WEIGHT SHOULD BE RECORDED IN POUNDS]
DIFINTRO
HFHINTRO
no entry
Now, I'm going to ask about how difficult it is, on average, for [you/(SP)] to do certain kinds of activities. Please
tell me for each activity whether [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a lot of
difficulty, or [is/are] not able to do it.
SHOW CARD HF3
DIFSTOOP
HFH1
code 1
How much difficulty, if any, [do you/does (SP)] have stooping, crouching, or kneeling? Would you say [you
have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or [is/are] not able to do it?
SHOW CARD HF3
DIFLIFT
HFH2
code 1
How much difficulty, if any, [do you/does (SP)] have lifting or carrying objects as heavy as 10 pounds, like a
heavy bag of groceries?
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or [is/are] not able to do it?]
SHOW CARD HF3
DIFREACH
HFH3
code 1
What about reaching or extending arms above shoulder level?
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or [is/are] not able to do it?]
SHOW CARD HF3
DIFWRITE
HFH4
code 1
How much difficulty, if any, [do you/does (SP)] have either writing or handling and grasping small objects?
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or [is/are] not able to do it?]
SHOW CARD HF3
DIFWALK
HFH5
code 1
What about walking a quarter of a mile - that is, about 2 or 3 blocks?
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
lot of difficulty, or [is/are] not able to do it?]
PHYSACTINTRO
HFH10INT
no entry
We are interested in two types of physical activity - vigorous and moderate. Vigorous activities cause large
increases in breathing or heart rate. Moderate activities cause small increases in breathing or heart rate. First I
will ask about the vigorous activities that [you do/(SP) does].
HFD1A - FOODTRBL
HFE1 - HEIGHTFT
HFE1 - HEIGHTIN
HFE1 - WEIGHT
(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED
HFHINTRO - DIFINTRO
(01) CONTINUE
(-7) Empty
HFH1 - DIFSTOOP
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused
(01) CONTINUE
(-7) Empty
HFH2 - DIFLIFT
HFH3 - DIFREACH
HFH4 - DIFWRITE
HFH5 - DIFWALK
HFH10INT - PHYSACTINTRO
HFH10 - VIGUNIT
Page 4 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
VIGUNIT
HFH10
quantity unit
Revised HFQ- Health Status and Functioning
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused
(01) HFH10 - VIGNUM
(02) HFH10 - VIGNUM
(03) HFH10 - VIGNUM
(04) HFH10 - VIGNUM
(96) HFH11 - MODUNIT
(-8) HFH11 - MODUNIT
(-9) HFH11 - MODUNIT
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HFH11 - MODUNIT
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused
(01) HFH11 - MODNUM
(02) HFH11 - MODNUM
(03) HFH11 - MODNUM
(04) HFH11 - MODNUM
(96) HFH12 - MUSUNIT
(-8) HFH12 - MUSUNIT
(-9) HFH12 - MUSUNIT
(01) continous answer
(01) HFH12 - MUSUNIT
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused
(01) HFH12 - MUSNUM
(02) HFH12 - MUSNUM
(03) HFH12 - MUSNUM
(04) HFH12 - MUSNUM
(96) HFJINTRO - MEDCONDINTRO
(-8) HFJINTRO - MEDCONDINTRO
(-9) HFJINTRO - MEDCONDINTRO
In a typical week, how much time [you/(SP)] spend doing exercises to increase [your/(SP)'s] muscle strength or
flexibility, such as lifting weights, push-ups, sit-ups, stretching, or yoga?
(01) Continunous answer
HFJINTRO - MEDCONDINTRO
(01) CONTINUE
(-7) Empty
BOX HFJ1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ2 - OCHBP
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ2
(02) HFJ4 - OCMYOCAR
(-8) HFJ4 - OCMYOCAR
(-9) HFJ4 - OCMYOCAR
In a typical week, how much time [do you/does (SP)] spend doing vigorous activities, such as team sports,
running, aerobics, heavy house or yard work, or anything else that causes large increases in breathing or heart
rate?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
VIGNUM
HFH10
quantity unit
In a typical week, how much time [do you/does (SP)] spend doing vigorous activities, such as team sports,
running, aerobics, heavy house or yard work, or anything else that causes large increases in breathing or heart
rate?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
MODUNIT
HFH11
quantity unit
In a typical week, how much time [do you/does (SP)] spend doing moderate activities, such as brisk walking,
bicycling, gardening, golf, swimming, or vacuuming?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
MODNUM
HFH11
numeric
In a typical week, how much time [do you/does (SP)] spend doing moderate activities, such as brisk walking,
bicycling, gardening, golf, swimming, or vacuuming?
Now I’m going to ask you about activities [you/(SP)] may do to increase [your/(SP)'s] muscle strength or
flexibility.
MUSUNIT
MUSNUM
HFH12
HFH12
quantity unit
numeric
In a typical week, how much time [you/(SP)] spend doing exercises to increase [your/(SP)'s] muscle strength or
flexibility, such as lifting weights, push-ups, sit-ups, stretching, or yoga?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
Next, I'm going to read a list of medical conditions. [Since (LAST HF MONTH YEAR) ha s/Has] a doctor or other
health professional [ever] told [you/(SP)] that [you/he/she] had any of these conditions?
MEDCONDINTRO
HFJINTRO
no entry
[INTERVIEWER: IF THE SP IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE RESPONSE
RECORDED SHOULD BE "YES" TO INDICATE THAT THE SP HAS THE CONDITION.]
OCARTERY
BOX HFJ1
routing
HFJ1
yes/no
IF SP HAS EVER REPORTED HAVING HARDENING OF THE ARTERIES IN A PREVIOUS ROUND
(sample_person.P_OCARTERY=1), GO TO HFJ2 - OCHBP.
ELSE GO TO HFJ1 - OCARTERY.
[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...
hardening of the arteries or arteriosclerosis?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ ever] told [you/(SP)] that
[you/he/she] [still has/still have/had/has/have...]
OCHBP
HFJ2
yes/no
hypertension, sometimes called high blood pressure?
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE
RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
Page 5 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFJ2
Revised HFQ- Health Status and Functioning
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ3 - YRHBP.
ELSE GO TO HFJ4 - OCMYOCAR.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] still had
(01) YES
hypertension or high blood pressure?
(02) NO
(-8) Don't Know
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE
(-9) Refused
RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
YRHBP
HFJ3
yes/no
OCMYOCAR
HFJ4
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
a myocardial infarction or heart attack?
BOX HFJ3
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ5 - YRMYOCAR.
ELSE GO TO HFJ6 - OCCHD.
YRMYOCAR
HFJ5
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
myocardial infarction or heart attack?
OCCHD
HFJ6
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] angina pectoris or coronary heart disease?
BOX HFJ4
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ7 - YRCHD.
ELSE GO TO HFJ8 - OCCFAIL.
YRCHD
HFJ7
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
episode of angina pectoris or coronary heart disease?
OCCFAIL
HFJ8
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [e ver] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] congestive heart failure?
YRCFAIL
HFJ4 - OCMYOCAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ3
(02) HFJ6 - OCCHD
(-8) HFJ6 - OCCHD
(-9) HFJ6 - OCCHD
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ6 - OCCHD
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ4
(02) HFJ8 - OCCFAIL
(-8) HFJ8 - OCCFAIL
(-9) HFJ8 - OCCFAIL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ8 - OCCFAIL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ5
(02) HFJ14 - OCHRTCND
(-8) HFJ14 - OCHRTCND
(-9) HFJ14 - OCHRTCND
BOX HFJ5
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ9 - YRCFAIL.
ELSE GO TO HFJ14 - OCHRTCND .
HFJ9
yes/no
(01) YES
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an (02) NO
episode of congestive heart failure?
(-8) Don't Know
(-9) Refused
HFJ14 - OCHRTCND
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] any other heart condition?
OCHRTCND
HFJ14
yes/no
[NOTE TO FI: This includes problems with the valves of the heart, such as aortic stenosis, and problems with the
rhythm of the heartbeat, such as atrial fibrillation.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ8
(02) HFJ16 - OCSTROKE
(-8) HFJ16 - OCSTROKE
(-9) HFJ16 - OCSTROKE
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ16 - OCSTROKE
[DO NOT RECORD THE NAME OF THE CONDITION AT THIS QUESTION.]
BOX HFJ8
routing
HFJ15
yes/no
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ15 - YRHRTCND.
ELSE GO TO HFJ16 - OCSTROKE.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
episode of any other heart condition?
YRHRTCND
[NOTE TO FI: This includes problems with the valves of the heart, such as aortic stenosis, and problems with the
rhythm of the heartbeat, such as atrial fibrillation.]
Page 6 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
OCSTROKE
HFJ16
yes/no
a stroke, a brain hemorrhage, or a cerebrovascular accident?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ9
(02) HFJ17A - OCCHOLES
(-8) HFJ17A - OCCHOLES
(-9) HFJ17A - OCCHOLES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ17A - OCCHOLES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFJ17B - YRCHOLES
(2) BOX HFJ29
(-8) BOX HFJ29
(-9) BOX HFJ29
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ29
[NOTE: This includes transient ischemic attack (TIA) which is sometimes referred to as a ministroke.]
YRSTROKE
BOX HFJ9
routing
HFJ17
yes/no
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ17 - YRSTROKE.
ELSE GO TO HFJ17A - OCCHOLES.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
stroke, a brain hemorrhage, or a cerebrovascular accident?
[NOTE: This includes transient ischemic attack (TIA) which is sometimes referred to as a ministroke.]
Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had high cholesterol?
OCCHOLES
HFJ17A
yes/no
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE
RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
high cholesterol?
YRCHOLES
HFJ17B
yes/no
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE
RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO HFJ45-BLOSWGHT.
ELSE IF be P_EVRLWGHT ^= YES THEN GO TO HFJ46-CLOSWGHT.
ELSE GO TO HFJ18 - OCCSKIN.
BOX HFJ29
BLOSWGHT
HFJ45
yes/no
To lower risk for certain diseases, [have you/ has (SP)] ever been told by a doctor or health professional to
control weight or lose weight?
CLOSWGHT
HFJ46
yes/no
To lower risk for certain diseases, since (SAMPLE_PERSON.DATE_FALLRND) [have you/ has (SP)] been told by a
doctor or health professional to control weight or lose weight?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ18 - OCCSKIN
HFJ18 - OCCSKIN
[I've recorded that [you/(SP)] previously reported having had skin cancer.]
OCCSKIN
HFJ18
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ10
(02) HFJ20 - OCCANCER
(-8) HFJ20 - OCCANCER
(-9) HFJ20 - OCCANCER
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ20 - OCCANCER
[a new occurrence of] skin cancer?
YRCSKIN
BOX HFJ10
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ19 - YRCSKIN.
ELSE GO TO HFJ20 - OCCANCER.
HFJ19
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
occurrence of skin cancer?
Page 7 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
[I've recorded that [you/(SP)] previously reported having had a tumor, growth, malignancy, or cancer of the
[READ RESPONSES BELOW].]
OCCANCER
HFJ20
yes/no
[Since (LAST HF MONTH YEAR), has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had any [other] kind of cancer, malignancy, or tumor other than skin cancer?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ11
(02) BOX HFJ13
(-8) BOX HFJ13
(-9) BOX HFJ13
INCLUDE BENIGN OR NON-MALIGNANT TUMORS OR GROWTHS.
YRCANCER
BOX HFJ11
routing
HFJ21
yes/no
IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ21 - YRCANCER.
ELSE GO TO HFJ22 - OCCCODE.
(01) YES
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had any (02) NO
kind of cancer, malignancy, or tumor other than skin cancer?
(-8) Don't Know
(-9) Refused
(01) LUNG
(02) COLON (BOWEL)
(03) BREAST
(04) UTERUS
(05) PROSTATE
(06) BLADDER
(07) OVARY
(08) STOMACH
SHOW CARD HF4
(09) CERVIX
(10) BRAIN
[Since the first time a doctor or other health professional told [you/(SP)] that [you/he/she] had a cancer,
(11) KIDNEY
malignancy, or tumor, on/On] what part or parts of [your/(SP's)] body was the cancer or tumor other than skin (12) THROAT
cancer found?
(16) BLOOD
(17) BONE
[PROBE: Any other part?]
(18) ESOPHAGUS
CHECK ALL THAT APPLY
(19) GALL BLADDER
(20) LARYNX (WINDPIPE)
(21) LEUKOCYTES (LEUKEMIA)
(22) LIVER
(23) LYMPH NODES (LYMPHOMA)
(24) MOUTH/TONGUE/LIP
(25) PANCREAS
(26) RECTUM
(27) SOFT TISSUE/FAT
(28) TESTIS
(29) THYROID
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) BOX HFJ13
(02) BOX HFJ13
(03) BOX HFJ13
(04) BOX HFJ13
(05) BOX HFJ13
(06) BOX HFJ13
(07) BOX HFJ13
(08) BOX HFJ13
(09) BOX HFJ13
(10) BOX HFJ13
(11) BOX HFJ13
(12) BOX HFJ13
(16) BOX HFJ13
(17) BOX HFJ13
(18) BOX HFJ13
(19) BOX HFJ13
(20) BOX HFJ13
(21) BOX HFJ13
(22) BOX HFJ13
(23) BOX HFJ13
(24) BOX HFJ13
(25) BOX HFJ13
(26) BOX HFJ13
(27) BOX HFJ13
(28) BOX HFJ13
(29) BOX HFJ13
(91) HFJ22 - OCCOS
(-8) BOX HFJ13
(-9) BOX HFJ13
(01) [Continuous answer.]
BOX HFJ13
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ15
(02) BOX HFJ16
(-8) BOX HFJ16
(-9) BOX HFJ16
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ14
OCCCODE
HFJ22
code all
OCCOS
HFJ22
verbatim text
Specify the part of parts of your body where the cancer or tumor was found.
BOX HFJ13
routing
IF SP HAS EVER REPORTED HAVING RHEUMATOID ARTHRITIS IN A PREVIOUS ROUND
(sample_person.P_OCARTHRH=1), GO TO BOX HFJ13B.
ELSE GO TO HFJ24 - OCARTHRH.
HFJ24
yes/no
OCARTHRH
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
rheumatoid arthritis?
OCOSARTH
BOX HFJ13B
routing
HFJ24B
yes/no
HFJ22 - OCCCODE
IF SP HAS EVER REPORTED HAVING OSTEOARTHRITIS IN A PREVIOUS ROUND (sample_person.P_OCOSARTH=1),
GO TO BOX HFJ14.
ELSE GO TO HFJ24B-OCOSARTH.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
osteoarthritis?
Page 8 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
OCARTH
BOX HFJ14
routing
HFJ25
yes/no
Revised HFQ- Health Status and Functioning
IF SP HAS EVER REPORTED HAVING ARTHRITIS OTHER THAN RHEUMATOID ARTHRITIS IN A PREVIOUS ROUND
[sample_person.P_OCARTH=1], GO TO BOX HFJ16.
ELSE GO TO HFJ25 - OCARTH.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
(you/he/she) had...]
arthritis, other than rheumatoid or osteoarthritis?
YRARTHRD
BOX HFJ15
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ26 - YRARTHRD.
ELSE GO TO BOX HFJ16A.
HFJ26
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
arthritis, other than rheumatoid or osteoarthritis, in any part of [your/his/her] body?
BOX HFJ16
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ28 - OCMENTAL.
ELSE GO TO BOX HFJ16A.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ15
(02) BOX HFJ16
(-8) BOX HFJ16
(-9) BOX HFJ16
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ16
[Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had...]
OCMENTAL
OCALZMER
HFJ28
yes/no
BOX HFJ16A
routing
HFJ29A
yes/no
(01) YES
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY:] This is also known as intellectual development disorder or a general learning disability. (-9) Refused
It was formerly known as mental retardation.
an intellectual disability?
IF SP HAS EVER REPORTED HAVING ALZHEIMER’S DISEASE IN A PREVIOUS ROUND
(sample_person.P_OCALZMER=1), GO TO BOX HFJ16B.
ELSE GO TO HFJ29A - OCALZMER.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
Alzheimer's disease?
OCDEMENT
BOX HFJ16B
routing
HFJ29B
yes/no
BOX HFJ16A
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ16B
(02) BOX HFJ16B
(-8) BOX HFJ16B
(-9) BOX HFJ16B
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ30
IF SP HAS EVER REPORTED HAVING DEMENTIA IN A PREVIOUS ROUND (sample_person.P_OCDEMENT=1), GO TO
BOX HFJ30
ELSE GO TO HFJ29B - OCDEMENT.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
any type of dementia other than Alzheimer's disease?
BOX HFJ30
routing
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO HFJ47-BASKDEPRS.
ELSE IF P_EVRDPRSS ^= YES THEN GO TO HFJ48-CASKDEPRS.
ELSE GO TO HFJ30AA - OCDEPRSS.
BASKDEPRS
HFJ47
yes/no
(01) YES
Has a doctor or other health professional ever asked [you/(SP)] if there was a period of time when [you/he/she] (02) NO
(-8) Don't Know
felt sad, empty, or depressed?
(-9) Refused
HFJ30AA - OCDEPRSS
CASKDEPRS
HFJ48
yes/no
(01) YES
Since (SAMPLE_PERSON.DATE_FALLRND), has a doctor or other health professional asked [you/(SP)] if there was (02) NO
(-8) Don't Know
a period of time when [you/he/she] felt sad, empty, or depressed?
(-9) Refused
HFJ30AA - OCDEPRSS
OCDEPRSS
HFJ30AA
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
depression?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ17A
(02) HFJ30A - OCPSYCHO
(-8) HFJ30A - OCPSYCHO
(-9) HFJ30A - OCPSYCHO
Page 9 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
YRDEPRSS
Revised HFQ- Health Status and Functioning
BOX HFJ17A
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ30BB - YRDEPRSS.
ELSE GO TO HFJ30A - OCPSYCHO.
HFJ30BB
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
depression?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
OCPSYCHO
HFJ30A
yes/no
a mental or psychiatric disorder other than depression?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ30A - OCPSYCHO
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ17B
(02) BOX HFJ19
(-8) BOX HFJ19
(-9) BOX HFJ19
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ19
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ33 - OCBRKHIP
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ20
(02) BOX HFJ21
(-8) BOX HFJ21
(-9) BOX HFJ21
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ21
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ22
[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]
YRPSYCHO
BOX HFJ17B
routing
HFJ31A
yes/no
IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ31A - YRPSYCHO.
ELSE GO TO BOX HFJ19.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
mental or psychiatric disorder other than depression?
[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]
OCOSTEOP
BOX HFJ19
routing
HFJ32
yes/no
IF SP HAS EVER REPORTED HAVING OSTEOPOROSIS IN A PREVIOUS ROUND (sample_person.P_OCOSTEOP=1),
GO TO HFJ33 - OCBRKHIP.
ELSE GO TO HFJ32 - OCOSTEOP.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
osteoporosis, sometimes called fragile or soft bones?
OCBRKHIP
HFJ33
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]]
a broken hip?
YRBRKHIP
OCPARKIN
BOX HFJ20
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ34 - YRBRKHIP.
ELSE GO TO BOX HFJ21.
HFJ34
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
broken hip?
BOX HFJ21
routing
IF SP HAS EVER REPORTED HAVING PARKINSON’S DISEASE IN A PREVIOUS ROUND
(sample_person.P_OCPARKIN=1), GO TO BOX HFJ22.
ELSE GO TO HFJ35 - OCPARKIN.
HFJ35
yes/no
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
Parkinson's disease?
BOX HFJ22
routing
IF SP HAS EVER REPORTED HAVING EMPHYSEMA, ASTHMA OR COPD IN A PREVIOUS ROUND
(sample_person.P_OCEMPHYS=1), GO TO HFJ37 - OCPPARAL.
ELSE GO TO HFJ36 - OCEMPHYS.
Page 10 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
OCEMPHYS
HFJ36
yes/no
emphysema, asthma, or COPD?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFJ37 - OCPPARAL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ23
(02) BOX HFJ24
(-8) BOX HFJ24
(-9) BOX HFJ24
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ24
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ25
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFJ26
(02) BOX HFCA
(-8) BOX HFCA
(-9) BOX HFCA
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFCA
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFJ41B - OCDTYPE
(02) BOX HFJ27
(-8) BOX HFJ27
(-9) BOX HFJ27
COPD=CHRONIC OBSTRUCTIVE PULMONARY DISEASE
OCPPARAL
HFJ37
yes/no
IF SP IS OBVIOUSLY PARTIALLY OR COMPLETELY PARALYZED, SELECT "YES" AND DO NOT ASK. OTHERWISE, ASK:
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
complete or partial paralysis?
YRPPARAL
BOX HFJ23
routing
IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3, GO TO HFJ38 - YRPPARAL.
ELSE GO TO BOX HFJ24.
HFJ38
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
complete or partial paralysis?
BOX HFJ24
routing
IF SP HAS EVER REPORTED AN ABSENCE OR LOSS OF ARM OR LEG IN A PREVIOUS ROUND
(sample_person.P_OCAMPUTE=1), GO TO BOX HFJ25.
ELSE GO TO HFJ39 - OCAMPUTE.
HFJ39
yes/no
IF SP IS OBVIOUSLY MISSING ONE OR MORE LIMBS, SELECT "YES" AND DO NOT ASK. OTHERWISE, ASK:
OCAMPUTE
What about absence or loss of an arm or a leg?
HAVEPROS
BOX HFJ25
routing
HFJ40
yes/no
IF SP IS FEMALE (ROSTSEX=2 or (roster.ROSTSEX=2 where ROSTNUM=1)), GO TO BOX HFCA.
ELSE GO TO HFJ40 - HAVEPROS.
[[Before (you/[SP]) had prostate surgery, did a doctor or other health professional ever tell/Since (LAST HF
MONTH YEAR), has/Has] a doctor or other health professional [ever] told [you/(SP)] that [you/he] had...]
an enlarged prostate or benign prostatic hypertrophy (BPH)?
YRPROST
BOX HFJ26
routing
IF SP IS IN THE BASELINE SAMPLE (sample_person.INTTYPE=3), GO TO HFJ41 - YRPROST.
ELSE GO TO BOX HFCA.
HFJ41
yes/no
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he] had an
enlarged prostate or benign prostatic hypertrophy (BPH)?
BOX HFCA
routing
IF P_OCBETES=YES, GO TO BOX HFCB.
ELSE IF SP IS IN THE BASELINE SAMPLE (sample_person.INTTYPE=3), GO TO HFJ41A-OCBETES.
ELSE GO TO YRBETES-YRBETES.
Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had any type of diabetes,
including:
OCBETES
HFJ41A
yes/no
sugar diabetes, high blood sugar, [borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline
diabetes, or pre-diabetes]?
Page 11 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
Since [SAMPLE_PERSON.DATE_FALLRND], has a doctor or other health professional told [you/(SP)] that
[you/he/she] had any type of diabetes, including:
YRBETES
YRBETES
yes/no
sugar diabetes, high blood sugar, [borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline
diabetes, or pre-diabetes]?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFJ41B - OCDTYPE
(02) BOX HFJ27
(-8) BOX HFJ27
(-9) BOX HFJ27
(01) TYPE 1
(02) TYPE 2
(03) BORDERLINE
(04) PRE-DIABETES
(05) GESTATIONAL (PREGNANCY-RELATED)
(91) SOME OTHER TYPE
(-8) Don't Know
(-9) Refused
(01) BOX HFCB
(02) BOX HFCB
(03) BOX HFCB
(04) BOX HFCB
(05) BOX HFCB
(91) HFJ41B - OCDTYPOS
(-8) BOX HFCB
(-9) BOX HFCB
(01) [Continuous answer.]
BOX HFCB
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFJ27
SHOW CARD HF5
Looking at this card, please tell me which type of diabetes the doctor or other health professional said that [you
have/(SP) has].
OCDTYPE
HFJ41B
code 1
[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT TYPE OF
DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]
[EXPLAIN IF NECESSARY: “Type 1” was formerly called “insulin dependent” or “juvenile-onset” diabetes. This
type of diabetes usually develops during childhood or adolescence; but, it also can develop in adults.
“Type 2” was formerly called “non-insulin dependent” or “adult-onset” diabetes. Until recently, this type of
diabetes was found only in adults; but, now it is also occurring in children.]
SOME OTHER TYPE (SPECIFY)
OCDTYPOS
OCDVISIT
HFJ41B
verbatim text
BOX HFCB
routing
IF (P_OCBETES ^= YES AND (OCBETES = YES or YRBETES = YES)) OR (P_OCBETES = YES AND P_OCDVISIT ^= YES),
GO TO HFJ41C-OCDVISIT.
ELSE GO TO BOX HFJ27.
HFJ41C
yes/no
[Were you/Was (SP)] told on two or more different visits that [you/he/she] had diabetes?
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE AND SP'S AGE AT TIME OF CURRENT MEDICARE ELIGIBILITY WAS UNDER
65 (sample_person.INTTYPE=3 and AGECALC<65 and greater than 0) THEN
IF SP REPORTED “YES” TO AT LEAST ONE HFJ CONDITION, GO TO HFJ42 - EMCOND.
ELSE IF SP REPORTED “NO” TO ALL HFJ CONDITIONS , GO TO HFJ43 - EMCAUSEVB.
ELSE IF SP IS NOT IN THE SUPPLEMENTAL SAMPLE OR SP'S AGE AT TIME OF CURRENT MEDICARE ELIGIBILITY WAS
NOT UNDER 65 THEN GO TO HFPINTRO - HLTHCAREINTRO.
BOX HFJ27
[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT TYPE OF
DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]
You told me that [you have/(SP) has] had [READ CONDITIONS LISTED BELOW]. [Was this/Were any of these] the
original cause of [your/(SP's)] becoming eligible for Medicare?
EMCOND
HFJ42
yes/no
EMCAUSEVB
HFJ43
verbatim text
(01) YES
(02) NO
(-8) Don't Know
[NOTE THAT CONDITIONS MAY NOT BE DISPLAYED WITH THE EXACT CONDITION NAME THAT WAS USED EARLIER (-9) Refused
IN THE INTERVIEW (E.G., HYPERTENSION CAN ALSO BE CALLED HIGH BLOOD PRESSURE AT DIFFERENT
QUESTIONS).]
[LIST ALL CONDITIONS WHERE "YES" ANSWER RECORDED AT HFJ1 THROUGH HFJ41C]
What was the original cause of [your/(SP's)] becoming eligible for Medicare?
RECORD VERBATIM.
(01) [Continuous answer.]
(01) BOX HFJ28
(02) HFJ43 - EMCAUSEVB
(-8) HFPINTRO - HLTHCAREINTRO
(-9) HFPINTRO - HLTHCAREINTRO
HFPINTRO - HLTHCAREINTRO
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFJ28
routing
Revised HFQ- Health Status and Functioning
IF SP RESPONDED “YES” TO ONLY ONE HFJ CONDITION, GO TO HFPINTRO - HLTHCAREINTRO.
ELSE GO TO HFJ44 - EMCODE.
EMCODE
HFJ44
code all
Which of these conditions was the cause of [your/(SP's)] becoming eligible for Medicare?
[PROBE: Any other condition?]
CHECK UP TO 8 CONDITIONS.
(01) ARTERIES HARDENING
(02) HYPERTENSION
(03) HEART ATTACK
(04) HEART DISEASE
(05) CONGESTIVE HEART FAILURE
(06) HEART VALVE PROBLEM
(07) HEART RHYTHM PROBLEM
(08) OTHER HEART PROBLEM
(09) STROKE OR HEMORRHAGE
(10) SKIN CANCER
(11) CANCER/TUMOR
(12) RHEUMATOID ARTHRITIS
(26) OSTEOARTHRITIS
(13) OTHER ARTHRITIS
(14) INTELLECTUAL DISABILITY
(15) ALZHEIMER'S
(16) DEMENTIA
(17) DEPRESSION
(18) MENTAL DISORDER
(19) OSTEOPOROSIS
(20) BROKEN HIP
(21) PARKINSON'S
(22) EMPHYSEMA/ASTHMA/COPD
(23) PARALYSIS
(24) LOSS OF LIMB
(25) DIABETES
(91) OTHER
(-8) Don't Know
(-9) Refused
EMOS
HFJ44
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) HFPINTRO - HLTHCAREINTRO
(02) HFPINTRO - HLTHCAREINTRO
(03) HFPINTRO - HLTHCAREINTRO
(04) HFPINTRO - HLTHCAREINTRO
(05) HFPINTRO - HLTHCAREINTRO
(06) HFPINTRO - HLTHCAREINTRO
(07) HFPINTRO - HLTHCAREINTRO
(08) HFPINTRO - HLTHCAREINTRO
(09) HFPINTRO - HLTHCAREINTRO
(10) HFPINTRO - HLTHCAREINTRO
(11) HFPINTRO - HLTHCAREINTRO
(12) HFPINTRO - HLTHCAREINTRO
(26) HFPINTRO - HLTHCAREINTRO
(13)HFPINTRO - HLTHCAREINTRO
(14) HFPINTRO - HLTHCAREINTRO
(15) HFPINTRO - HLTHCAREINTRO
(16) HFPINTRO - HLTHCAREINTRO
(17) HFPINTRO - HLTHCAREINTRO
(18) HFPINTRO - HLTHCAREINTRO
(19) HFPINTRO - HLTHCAREINTRO
(20) HFPINTRO - HLTHCAREINTRO
(21) HFPINTRO - HLTHCAREINTRO
(22) HFPINTRO - HLTHCAREINTRO
(23) HFPINTRO - HLTHCAREINTRO
(24) HFPINTRO - HLTHCAREINTRO
(25) HFPINTRO - HLTHCAREINTRO
(91) HFJ44 - EMOS
(-8) HFPINTRO - HLTHCAREINTRO
(-9) HFPINTRO - HLTHCAREINTRO
HFPINTRO - HLTHCAREINTRO
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Revised HFQ- Health Status and Functioning
HFPINTRO
no entry
Now I want to ask you about some things that [you/(SP)] may be doing to maintain [your/his/her] health, either
by getting tested for health problems or by taking care of conditions that [you have/she has/he has].
BOX HFP1A
routing
IF (P_OCBETES ^= 1/YES) AND (HFJ41A – OCBETES = 1/Yes or YRBETES - YRBETES = 1/YES) AND (HFJ41B OCDTYPE ^= 5/GESTATIONAL), GO TO HFP1 - DIAAGE.
ELSE GO TO BOX HFC2.
HFP1
numeric
I recorded that [you were/(SP) was] told by a doctor or other health professional that [you have/she has/he has] (01) [Continuous answer.]
[Type 1 diabetes/Type 2 diabetes/borderline diabetes/pre-diabetes/diabetes].
(-7) Empty
(-8) Don't Know
How old [were you/was (SP)] when [you were/he was/she was] first told that [you/he/she] had diabetes?
(-9) Refused
BOX HFP2
routing
IF THE SP IS FEMALE (ROSTSEX=2) AND (HFP1 – DIAAGE is >= 12 and is <= 45) OR (HFP1 – DIAAGE = DK OR RF),
GO TO HFP2 - DIAPRGNT.
ELSE GO TO HFP4 - DIAINSUL.
DIAPRGNT
HFP2
yes/no
Did [you/(SP)] have diabetes only during a pregnancy?
DIAINSUL
HFP4
list
HLTHCAREINTRO
DIAAGE
DIAMEDS
DIATEST
DIASORES
DIAPRESS
DIAASPRN
HFP4
HFP4
HFP4
HFP4
HFP4
list
list
list
list
list
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take insulin?
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take prescription diabetes pills or oral diabetes medicine?
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
test [your/his/her] blood for sugar or glucose?
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
check for sores or irritations on [your/his/her] feet?
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
measure [your/his/her] blood pressure at home?
Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take aspirin regularly for [your/his/her] diabetes?
BOX HFP3
routing
(01) CONTINUE
(-7) Empty
(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
BOX HFP1A
BOX HFP2
(01) BOX HFC2
(02) HFP4 - DIAINSUL
(-8) BOX HFC2
(-9) BOX HFC2
HFP4 - DIAMEDS
HFP4 - DIATEST
HFP4 - DIASORES
HFP4 - DIAPRESS
HFP4 - DIAASPRN
BOX HFP3
IF HFP4 - DIAINSUL = 1/Yes, GO TO HFP5 - INSUTAKE.
ELSE IF HFP4 - DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
INSUTAKE
HFP5
quantity unit
How often [do you/does (SP)] take insulin?
INSUDAY
INSUWEEK
HFP5
HFP5
quantity unit
quantity unit
How often [do you/does (SP)] take insulin?
How often [do you/does (SP)] take insulin?
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) USE INSULIN PUMP
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) HFP5 - INSUDAY
(02) HFP5 - INSUWEEK
(03) BOX HFP4
(-8) BOX HFP4
(-9) BOX HFP4
BOX HFP4
BOX HFP4
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFP4
routing
Revised HFQ- Health Status and Functioning
IF HFP4 – DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
MEDSTAKE
HFP6
quantity unit
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(-8) Don't Know
(-9) Refused
MEDDAY
MEDWEEK
MEDMONTH
HFP6
HFP6
HFP6
quantity unit
quantity unit
quantity unit
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?
How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?
(01) [Continuous answer.]
(01) [Continuous answer.]
(01) [Continuous answer.]
BOX HFP5
routing
IF HFP4 – DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested (04) NUMBER OF TIMES PER YEAR
by a health professional.]
(-8) Don't Know
(-9) Refused
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
TESTTAKE
HFP7
quantity unit
TESTDAY
HFP7
quantity unit
TESTWEEK
HFP7
quantity unit
TESTMNTH
HFP7
quantity unit
TESTYEAR
HFP7
quantity unit
BOX HFP6
routing
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested
by a health professional.]
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested
by a health professional.]
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested
by a health professional.]
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested
by a health professional.]
IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
HFP8
quantity unit
SOREDAY
HFP8
quantity unit
SOREWEEK
HFP8
quantity unit
SOREMNTH
HFP8
quantity unit
SOREYEAR
HFP8
quantity unit
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
(01) HFP7 - TESTDAY
(02) HFP7 - TESTWEEK
(03) HFP7 - TESTMNTH
(04) HFP7 - TESTYEAR
(-8) BOX HFP6
(-9) BOX HFP6
BOX HFP6
(01) [Continuous answer.]
BOX HFP6
(01) [Continuous answer.]
BOX HFP6
(01) [Continuous answer.]
BOX HFP6
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they (04) NUMBER OF TIMES PER YEAR
are checked by a health professional.]
(-8) Don't Know
(-9) Refused
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
BOX HFP5
BOX HFP5
BOX HFP5
(01) [Continuous answer.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
SORECHEK
(01) HFP6 - MEDDAY
(02) HFP6 - MEDWEEK
(03) ) HFP6 - MEDMONTH
(-8) BOX HFP5
(-9) BOX HFP5
(01) HFP8 - SOREDAY
(02) HFP8 - SOREWEEK
(03) HFP8 - SOREMNTH
(04) HFP8 - SOREYEAR
(-8) HFP10 - DIATENYR
(-9) HFP10 - DIATENYR
(01) [Continuous answer.]
HFP10 - DIATENYR
(01) [Continuous answer.]
HFP10 - DIATENYR
(01) [Continuous answer.]
HFP10 - DIATENYR
(01) [Continuous answer.]
HFP10 - DIATENYR
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
DIATENYR
HFP10
yes/no
In the past year has a doctor or other health professional examined [your/his/her] feet for sores or irritations?
DIADRSAW
HFP11
numeric
About how many times in the past year [have you/has (SP)] seen a doctor or other health professional for
[your/his/her] diabetes?
DIAHEMOC
HFP13
numeric
A test of hemoglobin "A one C" measures the average level of blood sugar over the past three months. It is
usually done in a doctor's office. About how many times in the past year has a doctor or other health
professional checked [you/(SP)] for hemoglobin "A one C"?
SHOW CARD HF6
DIACTRLD
HFP14
code 1
DIAHYPO
HFP14A1
yes/no
Would you say that [your/(SP)'s] blood sugar is well controlled all of the time, most of the time, some of the
time, a little of the time, or none of the time? By "well controlled" we mean a recent hemoglobin "A one C"
result of 7.5 or less or an average fasting blood test of 140 or less.
In the past year, [have you/has (SP)] experienced hypoglycemia, sometimes called low blood sugar or an insulin
reaction?
Please think about the most serious episode of hypoglycemia that [you have/(SP) has] experienced in the past
year.
DIAHYPTR
HFP14A2
code 1
[Were you/Was (SP)] able to treat [yourself/himself/herself] by taking some form of sugar, did [you/he/she]
require treatment from others, or did [you/he/she] require treatment by a hospital?
[EXPLAIN IF NECESSARY: Treatment by a hospital includes being treated in the emergency room or outpatient
department of a hospital, or being admitted as an inpatient.]
BOX HFCC
routing
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) , GO TO HFP14A3-DIAFTEVR.
ELSE GO TO HFP14A-DIAFEET.
DIAFTEVR
HFP14A3
yes/no
[Have you/Has (SP)] ever had any problems with [your/his/her] feet as a result of [your/his/her] diabetes?
DIAFEET
HFP14A
yes/no
[Do you/Does (SP)] currently have any problems with [your/his/her] feet as a result of [your/his/her] diabetes?
BOX HFCD
routing
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIANEURO.
ELSE IF P_DNEURO ^= YES, GO TO YRDNEURO-YRDNEURO.
ELSE GO TO BOX HFCE.
People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been
told by a doctor or other health professional that [you/he/she] had any of the following problems with
[your/his/her] feet as a result of [your/his/her] diabetes.
DIANEURO
HFP14B
list
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) ALL OF THE TIME
(02) MOST OF THE TIME
(03) SOME OF THE TIME
(04) A LITTLE OF THE TIME
(05) NONE OF THE TIME
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) SELF TREATMENT
(02) TREATMENT FROM OTHERS
(03) HOSPITAL TREATMENT
(-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
HFP11 - DIADRSAW
HFP13 - DIAHEMOC
HFP14 - DIACTRLD
HFP14A1 - DIAHYPO
(01) HFP14A2 - DIAHYPTR
(02) BOX HFCC
(-8) BOX HFCC
(-9) BOX HFCC
BOX HFCC
(01) HFP14A - DIAFEET
(02) HFP15 - DIAEYPRB
(-8) HFP15 - DIAEYPRB
(-9) HFP15 - DIAEYPRB
BOX HFCD
BOX HFCE
Neuropathy or nerve damage, which may cause pain or numbness in the feet?
Page 16 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
YRDNEURO
YRDNEURO
yes/no
Revised HFQ- Health Status and Functioning
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her]
feet as a result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused
BOX HFCE
Neuropathy or nerve damage, which may cause pain or numbness in the feet?
BOX HFCE
DIACIRCF
HFP14B
routing
list
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIACIRCF.
ELSE IF P_DCIRCF ^= YES, GO TO YRDCIRCF-YRDCIRCF.
ELSE GO TO BOX HFCF.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been
told by a doctor or other health professional that [you/he/she] had any of the following problems with
(01) YES
[your/his/her] feet as a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused
BOX HFCF.
Poor circulation or blood flow in the feet?
YRDCIRCF
YRDCIRCF
yes/no
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her]
feet as a result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused
BOX HFCF
Poor circulation or blood flow in the feet?
BOX HFCF
DIAULCER
HFP14B
routing
list
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIAULCER.
ELSE IF P_DULCER ^= YES, GO TO YRDULCER-YRDULCER.
ELSE GO TO BOX HFCG.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been
told by a doctor or other health professional that [you/he/she] had any of the following problems with
(01) YES
[your/his/her] feet as a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused
BOX HFCG
Foot ulcers?
YRDULCER
YRDULCER
yes/no
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her]
(01) YES
feet as a result of [your/his/her] diabetes.]
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has (SP)] been told by a doctor or other health professional (-8) Don't Know
(-9) Refused
that [you/he/she] had…
BOX HFCG
Foot ulcers?
BOX HFCG
DIASKINC
HFP14B
routing
list
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIASKINC.
ELSE IF P_DSKINC ^= YES, GO TO YRDSKINC-YRDSKINC.
ELSE GO TO HFP15-DIAEYPRB.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been
told by a doctor or other health professional that [you/he/she] had any of the following problems with
(01) YES
[your/his/her] feet as a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused
HFP15 - DIAEYPRB
Calluses, infections, or other skin changes affecting the feet?
Page 17 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
YRDSKINC
YRDSKINC
yes/no
Revised HFQ- Health Status and Functioning
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her]
feet as a result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused
HFP15 - DIAEYPRB
Calluses, infections, or other skin changes affecting the feet?
DIAEYPRB
HFP15
yes/no
[Do you/Does (SP)] have any problems with [your/his/her] eyes as a result of [your/his/her] diabetes?
BOX HFCH
routing
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP16A1-DIAKDPEV.
ELSE GO TO HFP16-DIAKDPRB.
HFP16A1
yes/no
[Have you/Has (SP)] ever had any problems with [your/his/her] kidneys as a result of [your/his/her] diabetes?
DIAKDPEV
[EXPLAIN IF NECESSARY: This is tested by looking for protein in the urine.]
HFP16
yes/no
[Do you/Does (SP)] currently have any problems with [your/his/her] kidneys as a result of [your/his/her]
diabetes?
BOX HFCI
routing
IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP16A-DIAKIDNY.
ELSE IF P_DKIDNY ^= YES, GO TO YRDKIDNY-YRDKIDNY.
ELSE GO TO BOX HFC1.
DIAKIDNY
HFP16A
yes/no
YRDKIDNY
YRDKIDNY
yes/no
BOX HFC1
routing
DIAMNGE
HFP17
yes/no
CDIAMNGE
CDIAMNGE
yes/no
DIATRAIN
HFP18
code 1
DIAKDPRB
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFCH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFP16 - DIAKDPRB
(02) BOX HFC1
(-8) BOX HFC1
(-9) BOX HFC1
(01) BOX HFCI
(02) BOX HFC1
(-8) BOX HFC1
(-9) BOX HFC1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
Since [SAMPLE_PERSON.DATE_FALLRND], [Have you/Has (SP)] been told by a doctor or other health professional (02) NO
that [you have/she has/he has] chronic kidney disease?
(-8) Don't Know
(-9) Refused
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you have/she has/he has]
chronic kidney disease?
BOX HFC1
BOX HFC1
IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFP17-DIAMNGE.
ELSE GO TO HFP17A-CDIAMNGE.
(01) YES
[Have you/Has (SP)] ever participated in a diabetes self-management course or class, or received special training (02) NO
on how [you/he/she] can manage [your/his/her] diabetes?
(-8) Don't Know
(-9) Refused
(01) YES
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/has (SP)] participated in a diabetes self-management course (02) NO
(-8) Don't Know
or class, or received special training on how [you/he/she] can manage [your/his/her] diabetes?
(-9) Refused
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
When was the most recent time that [you/(SP)] participated in a diabetes self-management course or class or
(07) 6 YEARS TO LESS THAN 7 YEARS
received special training on how [you/he/she] can manage [your/his/her] diabetes?
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
[IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING, PROBE FOR THE MOST RECENT
(10) 9 YEARS TO LESS THAN 10 YEARS
TIME.]
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
(01) HFP18 - DIATRAIN
(02) BOX HFP7
(-8) BOX HFP7
(-9) BOX HFP7
BOX HFP7
BOX HFP7
Page 18 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFP7
routing
Revised HFQ- Health Status and Functioning
IF THE SP IS THE RESPONDENT (SPPROXY=1), GO TO HFP19 - DIAKNOW.
ELSE GO TO BOX HFR1.
SHOW CARD HF7
DIAKNOW
HFP19
code 1
How much do you think you know about managing your diabetes? Do you know . . .
DIASUPPS
DIAEVERT
HFP20
yes/no
Before today, did you know that Medicare now helps pay the cost of diabetic testing supplies and selfmanagement education for people with diabetes?
BOX HFC2
routing
IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFP21-DIAEVERT.
ELSE GO TO HFP21A-CDIAEVER.
HFP21
yes/no
[I have recorded that [you have/(SP) has] never been told by a doctor or other health professional that [you
have/she has/he has] diabetes.]
[Have you/Has (SP)] ever had a blood test to see if [you have/she has/he has] diabetes?
(01) just about everything you need to know,
(02) most of what you need to know,
(03) some of what you need to know,
(04) a little of what you need to know, or
(05) almost none of what you need to know about
managing your diabetes?
(-8) Don't Know
(-9) Refused
HFP20 - DIASUPPS
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFR1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFP22 - DIARECNT
(02) BOX HFP8
(-8) BOX HFP8
(-9) BOX HFP8
[I have recorded that [you have/(SP) has] never been told by a doctor or other health professional that [you
have/she has/he has] diabetes.]
(01) YES
(02) NO
(-8) Don't Know
Since [SAMPLE_PERSON.DATE_FALLRND, [have you/has (SP)] had a blood test to see if [you have/she has/he has]
(-9) Refused
diabetes?
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
When was the most recent time [you were/(SP) was] tested for diabetes?
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
CDIAEVER
HFP21A
yes/no
DIARECNT
HFP22
code 1
BOX HFP8
routing
IF THE SP IS THE RESPONDENT (SPPROXY=1), GO TO HFP23 - DIAAWARE.
ELSE GO TO HFP24 - DIARISK.
DIAAWARE
HFP23
yes/no
Before today, were you aware that there is a blood test to determine if a person has diabetes?
DIARISK
HFP24
yes/no
Has a doctor or other health professional ever told [you/(SP)] that [you are/he is/she is] at high risk for
diabetes?
DIASIGNS
HFP25
yes/no
In the past year, [have you/has (SP)] received any information about the signs, symptoms, or risk factors for
diabetes?
(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) HFP24 - DIARISK
(02) BOX HFP8
(-8) BOX HFP8
(-9) BOX HFP8
HFP24 - DIARISK
HFP24 - DIARISK
HFP25 - DIASIGNS
BOX HFR1
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFR1
routing
HFR1
yes/no
Revised HFQ- Health Status and Functioning
IF (SP HAS EVER HEARD ABOUT COLORECTAL OR COLON CANCER IS UNKNOWN P_COLHEAR=.) AND (SP HAS NOT
REPORTED HAVING COLON, RECTAL OR BOWEL CANCER IN THE CURRENT ROUND OR IN A PREVIOUS ROUND
(OCCCODE not in 02 and P_OCCCOLON^=1), GO TO HFR1 - COLHEAR.
ELSE GO TO BOX HFS1.
Now I'd like to talk about a different illness, colorectal or colon cancer, a disease of the lower intestines.
COLHEAR
Before today, had [you/SP] ever heard of colorectal or colon cancer?
BOX HFC3
COLHTEST
HFR3
routing
yes/no
HFR3A
yes/no
BOX HFC3
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFR5 - COLCARD
(02) BOX HFC4
(-8) BOX HFC4
(-9) BOX HFC4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFR5 - COLCARD
(02) BOX HFC4
(-8) BOX HFC4
(-9) BOX HFC4
IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFR3 - COLHTEST.
ELSE GO TO HFR3A - CCOLHTES.
The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible traces of blood
found in the stool. The doctor or other health professional can give the patient a kit to collect stool samples at
the patient’s home. The test is then sent to a laboratory for the results to be determined.
Has a doctor or other health professional ever given [you/(SP)] a home testing kit to test for blood in the stool?
CCOLHTES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible traces of blood
found in the stool. The doctor or other health professional can give the patient a kit to collect stool samples at
the patient’s home. The test is then sent to a laboratory for the results to be determined.
Since (SAMPLE_PERSON.DATE_FALLRND), Has a doctor or other health professional given [you/(SP)] a home
testing kit to test for blood in the stool?
BOX HFC4
routing
IF P_COLHKIT=YES, GO TO HFR4A - COLFDOC.
ELSE GO TO HFR4-COLHKIT.
COLHKIT
HFR4
yes/no
[Have you/Has SP] ever heard of this home testing kit?
COLFDOC
HFR4A
yes/no
Has a doctor or other health professional ever performed a fecal occult blood test to test for blood in the stool
while [you/(SP)] [were/was] at the doctor’s office?
COLCARD
HFR5
yes/no
BOX HFC5
routing
IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFR7 - COLRECNT.
ELSE GO TO BOX HFC6.
code 1
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
When did [you/(SP)] have [your/his/her] most recent blood stool test [(using a home testing kit)/(at the doctor's (06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
office)]?
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
[READ IF NECESSARY: The fecal occult blood test is a simple test for early signs of colon cancer. It detects
(10) 9 YEARS TO LESS THAN 10 YEARS
invisible traces of blood found in the stool.]
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
Did [you/(SP)] complete the samples and return them for [your/his/her] most recent test?
COLRECNT
HFR7
[READ IF NECESSARY: The fecal occult blood test is a simple test for early signs of colon cancer. It detects
invisible traces of blood found in the stool.]
(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
HFR4A - COLFDOC
(01) HFR7 - COLRECNT
(02) BOX HFC6
(-8) BOX HFC6
(-9) BOX HFC6
BOX HFC5
BOX HFC6
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
COLSCOPY
BOX HFC6
routing
HFR8
yes/no
Revised HFQ- Health Status and Functioning
IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFR8-COLSCOPY COLORECT-COLORECT.
ELSE GO TO HFRA8-CCOLSCOP CCOLOREC-CCOLOREC.
Another test for early signs of colon cancer is performed in the doctor's office. The doctor uses a flexible lighted
tube to examine the colon and rectum directly. This is called a sigmoidoscopy or colonoscopy.
[Have you/Has (SP)] ever had this exam?
COLORECT
COLORECT
yes/no
These next questions are about colorectal cancer screening. There are several different kinds of tests to check
for colon cancer.
Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube
into the rectum to look for polyps or cancer.
[Have you/Has (SP)] ever had either of these exams?
CORECTYP
CORECTYP
code 1
For a colonoscopy, the doctor checks the entire colon, and you are given medication through a
needle in your arm to make you sleepy, and told to have someone take you home. For a sigmoidoscopy, the
doctor checks only part of the colon and you are fully awake.
[Have you/Has (SP)] ever had a colonoscopy, a sigmoidoscopy, or both?
CCOLSCOP
HFR8A
yes/no
Another test for early signs of colon cancer is performed in the doctor's office. The doctor uses a flexible lighted
tube to examine the colon and rectum directly. This is called a sigmoidoscopy or colonoscopy.
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had this exam?
CCOLOREC
CCOLOREC
yes/no
These next questions are about colorectal cancer screening. There are several different kinds of tests to check
for colon cancer.
Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube
into the rectum to look for polyps or cancer.
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had either of these exams?
For a colonoscopy, the doctor checks the entire colon, and you are given medication through a
needle in your arm to make you sleepy, and told to have someone take you home. For a sigmoidoscopy, the
doctor checks only part of the colon and you are fully awake.
CCORECTP
CCORECTP
code 1
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had a colonoscopy, a sigmoidoscopy, or both?
WHENSCOP
HFR9
code 1
When did [you/(SP)] have [your/his/her] most recent sigmoidoscopy or colonoscopy?
BOX HFC7
routing
IF P_HEARSCOP=YES, GO TO BOX HFR2.
ELSE GO TO HFR10-HEARSCOP.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFR9 - WHENSCOP
(02) BOX HFC7
(-8) BOX HFC7
(-9) BOX HFC7
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) CORECTYP
(02) BOX HFC7
(-8) BOX HFC7
(-9) BOX HFC7
(01) Colonoscopy
(02) Sigmoidoscopy
(03) Both
(-8) Don't Know
(-9) Refused
(01) HFR9 - WHENSCOP
(02) HFR9 - WHENSCOP
(03) HFR9 - WHENSCOP
(-8) BOX HFC7
(-9) BOX HFC7
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFC7
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) CCORECTP
(02) BOX HFC7
(-8) BOX HFC7
(-9) BOX HFC7
(01) Colonoscopy
(02) Sigmoidoscopy
(03) Both
(-8) Don't Know
(-9) Refused
BOX HFC7
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
HFR13 - COLSCRNS
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
HEARSCOP
Revised HFQ- Health Status and Functioning
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFR10
yes/no
Before today, had [you/(SP}] ever heard of a sigmoidoscopy or colonoscopy?
BOX HFR2
routing
IF HFR3 - COLHTEST = 1/Yes or HFR4 - COLHKIT = 1/Yes, GO TO HFR13 - COLSCRNS.
ELSE GO TO BOX HFS1.
COLDRREC
HFR11
yes/no
Has a doctor or other health professional ever recommended that [you/(SP)] have this test?
COLSCRNS
HFR13
yes/no
Before today, did [you/(SP)] know that Medicare now pays the cost of screening tests for colorectal cancer?
BOX HFS1
routing
IF SP HAS EVER REPORTED HAVING OSTEPOPORIS IN THE CURRENT ROUND OR IN A PREVIOUS ROUND
(OCOSTEOP=1 or sample_person.P_OCOSTEOP-=1 GO TO BOX HFC8.
ELSE GO TO HFSINTRO - OSTINTRO.
OSTINTRO
HFSINTRO
no entry
Now I'd like to talk about a disease called osteoporosis, which can be treated if found early. In osteoporosis, the (01) CONTINUE
bones lose their calcium and become fragile and more easily broken.
(-7) Empty
OSTEVERT
HFS1
yes/no
[Have you/Has (SP)] ever talked with [your/his/her] doctor or other health professional about osteoporosis?
OSTHRISK
HFS2
yes/no
Has a doctor or other health professional ever told [you/(SP)] that [you are/he is/she is] at high risk for
osteoporosis?
OSTFRACT
HFS2A
yes/no
Have [you/(SP)] ever experienced a fracture that [your/his/her] doctor or other health professional told
[you/him/her] was related to osteoporosis?
BOX HFC8
routing
IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFS3-OSTTEST.
ELSE GO TO HFS3A-COSTTEST.
HFS3
yes/no
OSTTEST
There is a test to detect osteoporosis at an early stage, called Bone Mass Measurement or Bone Density
Measurement, or DEXA scan.
[Have you/Has (SP)] ever had a Bone Mass or Bone Density Measurement test?
There is a test to detect osteoporosis at an early stage, called Bone Mass Measurement or Bone Density
Measurement, or DEXA scan.
COSTTEST
HFS3A
yes/no
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had a Bone Mass or Bone Density Measurement
test?
OSTHEAR
BOX HFC9
routing
IF P_OSTHEAR=YES, GO TO HFS6 - OSTMASS.
ELSE GO TO HFS4-OSTHEAR.
HFS4
yes/no
Before today, had you ever heard of this test?
(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) HFR11 - COLDRREC
(02) BOX HFR2
(-8) BOX HFR2
(-9) BOX HFR2
HFR13 - COLSCRNS
BOX HFS1
HFS1 - OSTEVERT
(01) HFS2 - OSTHRISK
(02) BOX HFC8
(-8) BOX HFC8
(-9) BOX HFC8
HFS2A - OSTFRACT
BOX HFC8
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFS5 - OSTRECNT
(02) BOX HFC9
(-8) BOX HFC9
(-9) BOX HFC9
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFS6 - OSTMASS
(02) BOX HFC9
(-8) BOX HFC9
(-9) BOX HFC9
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFS6 - OSTMASS
(02) HFAC29 - HCTROUBL
(-8) HFAC29 - HCTROUBL
(-9) HFAC29 - HCTROUBL
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MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
OSTRECNT
HFS5
code 1
When was the most recent time that [you/(SP)] had a Bone Mass or Bone Density Measurement test?
OSTMASS
HFS6
yes/no
Before today, did you know that Medicare would pay for Bone Mass or Bone Density Measurement tests for
Medicare beneficiaries who are at risk for osteoporosis?
HCTROUBL
HFAC29
yes/no
(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Next, we are going to ask some questions about [your/(SP's)] health care needs during the past year.
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] had any trouble getting health care that [you/he/she] wanted (-8) Don't Know
or needed?
(-9) Refused
Why was that?
HCTCODE
HFAC30A
code all
HCTOTHOS
HFAC30A
verbatim text
BOX HFF6
routing
HFAC30B
yes/no
CGETAPPT
[PROBE: Any other reason?]
CHECK ALL THAT APPLY.
OTHER (SPECIFY)
IF RESPONSE TO HFAC30A - HCTCODE INCLUDES 8/DrDoesNotAcceptMedicare OR 10/DifficultyGettingAppt, GO
TO HFAC30D - OFFEXPLN.
ELSE GO TO HFAC30B - CGETAPPT.
Since (LAST HF MONTH YEAR), [have you/has (SP)] been told by a doctor’s office that they cannot schedule an
appointment with [you/(SP)]?
HFS6 - OSTMASS
HFAC29 - HCTROUBL
(01) HFAC30A - HCTCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
(01) SP DOES NOT HAVE MONEY
(02) COST IS TOO HIGH
(03) SERVICES/SUPPLIES NOT COVERED
(04) NEEDED TRANSPORTATION TO DOCTOR/HOSPITAL
(05) DIFFICULTY GETTING HOME HEALTH CARE
(06) NO TREATMENT AVAILABLE/DOCTOR WON’T
TREAT
(07) WAIT TOO LONG/DOCTOR TOO BUSY
(08) OWN DOCTOR DOESN’T ACCEPT
MEDICARE/COULDN’T FIND DOCTOR WHO ACCEPTS
MEDICARE
(09) NOT ELIGIBLE FOR PUBLIC COVERAGE
(10) DIFFICULTY GETTING APPOINTMENT/ DELAYS
BECAUSE SP ON MEDICARE
(11) DOCTOR REFERRED SP TO SPECIALIST OR OTHER
DOCTOR
(12) HMO REFERRAL PROCESS (DIFFICULTY GETTING)
(13) PROBLEMS WITH HMO DOCTORS NOT GOOD OR
AVAILABLE
(14) HMO WOULD NOT COVER OR PROVIDE SERVICE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(01) BOX HFF6
(02) BOX HFF6
(03) BOX HFF6
(04) BOX HFF6
(05) BOX HFF6
(06) BOX HFF6
(07) BOX HFF6
(08) BOX HFF6
(09) BOX HFF6
(10) BOX HFF6
(11) BOX HFF6
(12) BOX HFF6
(13) BOX HFF6
(14) BOX HFF6
(91) HFAC30A - HCTOTHOS
(-8) BOX HFF6
(-9) BOX HFF6
BOX HFF6
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFAC30C - CGETCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
Page 23 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
What were the reasons the doctor’s office offered as an explanation for not scheduling an appointment with
[you/(SP)]?
CGETCODE
HFAC30C
code all
[PROBE: Any other reason?]
CHECK ALL THAT APPLY
CGETOTOS
CGETOTOS
verbatim text
BOX HFF7
routing
OFFEXPLN
HFAC30D
yes/no
OFFEXVB
HFAC30E
verbatim text
HCDELAY
HFAC31
yes/no
PAYPROB
HFAC32A
yes/no
COLLAGNCY
HFAC32
yes/no
PAYOVRTM
HFAC32B
yes/no
IADLINTRO
HFKINTRO
no entry
Please specify the other reason.
(01) [Continuous answer.]
IF RESPONSE TO HFAC30C - CGETCODE INCLUDES 4/DocNotAcceptNewMedicare OR 7/DocNotAcceptMCAR, GO
TO HFAC30D - OFFEXPLN.
ELSE GO TO HFAC31 - HCDELAY.
(01) YES
Did the doctor’s office explain why [it is difficult for Medicare patients to get an appointment/Medicare is not
(02) NO
accepted] at that practice?
(-8) Don't Know
(-9) Refused
What was that explanation?
(01) [Continuous answer.]
RECORD VERBATIM.
(01) YES
Since (LAST HF MONTH YEAR), [have you/has (SP)] delayed seeking medical care because (you were/he was/she (02) NO
was) worried about the cost?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (LAST HF MONTH YEAR) [have you/has (SP)] had problems paying or were unable to pay any medical bills?
(-8) Don't Know
(-9) Refused
(01) YES
Because of problems paying medical bills since (LAST HF MONTH YEAR), [have you/has (SP)] been contacted by a (02) NO
collection agency?
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
[Do you /Does (SP)] currently have any medical bills that are being paid off over time?
(-8) Don't Know
(-9) Refused
Health problems can include physical, mental, emotional, or memory problems. I'd now like to ask you about
(01) CONTINUE
how health problems may affect [your/(SP)'s] ability to perform some other everyday activities. I’d like to know
(-7) Empty
whether [you have/(SP) has] any difficulty doing each activity by [yourself/himself/herself].
Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty...
PRBTELE
HFKA1
code 1
using the telephone?
[You said that using the telephone is something that [you don't/(SP) doesn't] do.]
DONTTELE
HFKA2
(01) DOCTOR DOES NOT ACCEPT INSURANCE PLAN
(02) ALL OF DOCTORS APPOINTMENTS WERE FULL
(03) DOCTOR IS NOT ACCEPTING ANY NEW PATIENTS
(04) DOCTOR IS NOT ACCEPTING NEW MEDICARE
PATIENTS
(05) DOCTORS HOURS CONFLICTED WITH
REQUIREMENTS OF SP
(06) DOCTOR DOES NOT ACCEPT MEDICAID
(07) DOCTOR DOES NOT ACCEPT MEDICARE AT ALL
(08) DOCTOR DOES NOT ACCEPT MEDICARE
ASSIGNMENT
(09) DOCTOR FELT ANOTHER PROVIDER WOULD BE
BETTER FOR SP
(91) OTHER
(-8) Don't Know
(-9) Refused
yes/no
Is this because of a physical, mental, emotional, or memory problem?
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HFF7
(02) BOX HFF7
(03) BOX HFF7
(04) BOX HFF7
(05) BOX HFF7
(06) BOX HFF7
(07) BOX HFF7
(08) BOX HFF7
(09) BOX HFF7
(91) HFAC30C - CGETOTOS
(-8) BOX HFF7
(-9) BOX HFF7
BOX HFF7
(01) HFAC30E - OFFEXVB
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY
HFAC31 - HCDELAY
HFAC32 A-PAYPROB
(01) HFAC32 - COLLAGNCY
(02) HFKINTRO - IADLINTRO
(-8) HFKINTRO - IADLINTRO
(-9) HFKINTRO - IADLINTRO
HFAC32B- PAYOVRTM
HFKINTRO - IADLINTRO
HFKA1 - PRBTELE
(01) HFKB1 - PRBLHWK
(02) HFKB1 - PRBLHWK
(03) HFKA2 - DONTTELE
(-8) HFKB1 - PRBLHWK
(-9) HFKB1 - PRBLHWK
HFKB1 - PRBLHWK
Page 24 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBLHWK
HFKB1
code 1
doing light housework (like washing dishes, straightening up, or light cleaning)?
DONTLHWK
HFKB2
yes/no
[You said that doing light housework (like washing dishes, straightening up, or light cleaning) is something that
[you don't/(SP) doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBHHWK
HFKC1
code 1
doing heavy housework (like scrubbing floors or washing windows)?
DONTHHWK
HFKC2
yes/no
[You said that doing heavy housework (like scrubbing floors or washing windows) is something that [you
don't/(SP) doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBMEAL
HFKD1
code 1
preparing [your/his/her] own meals?
[You said that preparing [your/his/her] own meals is something that [you don't/(SP) doesn't] do.]
DONTMEAL
HFKD2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBSHOP
HFKE1
code 1
shopping for personal items (such as toilet items or medicines)?
DONTSHOP
HFKE2
yes/no
[You said that shopping for personal items (such as toilet items or medicines) is something that [you don't/(SP)
doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBBILS
HFKF1
code 1
managing money (like keeping track of expenses or paying bills)?
DONTBILS
HELPTELE
HFKF2
yes/no
BOX HFKA1
routing
HFKA3
yes/no
[You said that managing money (like keeping track of expenses or paying bills) is something that [you don't/(SP)
doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?
IF HFKA1 - PRBTELE = 1/Yes OR HFKA2 – DONTTELE = 1/Yes, GO TO HFKA3 - HELPTELE.
ELSE GO TO BOX HFKB1.
[[You said that [your/(SP's)] health makes using the telephone difficult./You said that using the telephone is
something that [you don't do/(SP) doesn't do].]]
[Do you/Does (SP)] receive help from another person with...
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-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) HFKC1 - PRBHHWK
(02) HFKC1 - PRBHHWK
(03) HFKB2 - DONTLHWK
(-8) HFKC1 - PRBHHWK
(-9) HFKC1 - PRBHHWK
HFKC1 - PRBHHWK
(01) HFKD1 - PRBMEAL
(02) HFKD1 - PRBMEAL
(03) HFKC2 - DONTHHWK
(-8) HFKD1 - PRBMEAL
(-9) HFKD1 - PRBMEAL
HFKD1 - PRBMEAL
(01) HFKE1 - PRBSHOP
(02) HFKE1 - PRBSHOP
(03) HFKD2 - DONTMEAL
(-8) HFKE1 - PRBSHOP
(-9) HFKE1 - PRBSHOP
HFKE1 - PRBSHOP
(01) HFKF1 - PRBBILS
(02) HFKF1 - PRBBILS
(03) HFKE2 - DONTSHOP
(-8) HFKF1 - PRBBILS
(-9) HFKF1 - PRBBILS
HFKF1 - PRBBILS
(01) BOX HFKA1
(02) BOX HFKA1
(03) HFKF2 - DONTBILS
(-8) BOX HFKA1
(-9) BOX HFKA1
BOX HFKA1
(01) HFKA4 - PERSON_HLPRTELE
(02) BOX HFKB1
(-8) BOX HFKB1
(-9) BOX HFKB1
using the telephone?
Page 25 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRTEL
HFKA4
E
roster
You mentioned that [you receive/(SP) receives] help with using the telephone. Who gives that help?
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
HFKA4_NEW
HFKA4_NEW
ROSTREL
HFKA4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKA4_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFKB1
routing
IF HFKB1 - PRBLHWK = 1/Yes or HFKB2 - DONTLHWK = 1/Yes, GO TO HFKB3 - HELPLHWK.
ELSE GO TO BOX HFKC1.
[[You said that [your/(SP's)] health makes doing light housework (like washing dishes, straightening up, or light
cleaning) difficult./You said that doing light housework (like washing dishes, straightening up, or light cleaning)
is something that [you don't do/(SP) doesn't do].]]
HELPLHWK
HFKB3
yes/no
[Do you/Does (SP)] receive help from another person with...
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
IF PERSON_HLPRTELE = (N+1), GO TO
HFKA4_NEW-ROSTFNAM,
ELSE GO TO BOX HFKB1
HFKA4_NEW - ROSTLNAM
HFKA4_NEW - ROSTREL
(01) DO NOT DISPLAY
(02) BOX HFKB1
(03) BOX HFKB1
(04) BOX HFKB1
(05) BOX HFKB1
(06) BOX HFKB1
(07) BOX HFKB1
(08) BOX HFKB1
(09) BOX HFKB1
(10) BOX HFKB1
(11) BOX HFKB1
(12) BOX HFKB1
(13) BOX HFKB1
(14) BOX HFKB1
(50) DO NOT DISPLAY
(51) BOX HFKB1
(52) BOX HFKB1
(53) BOX HFKB1
(54) BOX HFKB1
(55) BOX HFKB1
(56) BOX HFKB1
(57) BOX HFKB1
(91) HFKA4_NEW - ROSTREOS
(-8) BOX HFKB1
(-9) BOX HFKB1
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
BOX HFKB1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFKB4 - PERSON_HLPRLHWK
(02) BOX HFKC1
(-8) BOX HFKC1
(-9) BOX HFKC1
doing light housework (like washing dishes, straightening up, or light cleaning)?
Page 26 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRLH
WK
HFKB4
roster
You mentioned that [you receive/(SP) receives] help with doing light housework (like washing dishes,
straightening up, or light cleaning). Who gives that help?
ROSTFNAM
ROSTLNAM
HFKB4_NEW
HFKB4_NEW
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
ROSTREL
HFKB4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKB4_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFKC1
routing
IF HFKC1 - PRBHHWK = 1/Yes or HFKC2 - DONTHHWK = 1/Yes, GO TO HFKC3 - HELPHHWK.
ELSE GO TO BOX HFKD1
HELPHHWK
HFKC3
yes/no
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
[[You said that [your/(SP's)] health makes doing heavy housework (like scrubbing floors or washing windows)
difficult./You said that heavy housework (like scrubbing floors or washing windows) is something that [you don't
(01) YES
do/(SP) doesn't do].]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with...
(-9) Refused
IF PERSON_HLPRLHWK = (N+1), GO TO
HFKB4_NEW-ROSTFNAM,
ELSE GO TO BOX HFKC1
HFKB4_NEW - ROSTLNAM
HFKB4_NEW - ROSTREL
(01) DO NOT DISPLAY
(02) BOX HFKC1
(03) BOX HFKC1
(04) BOX HFKC1
(05) BOX HFKC1
(06) BOX HFKC1
(07) BOX HFKC1
(08) BOX HFKC1
(09) BOX HFKC1
(10) BOX HFKC1
(11) BOX HFKC1
(12) BOX HFKC1
(13) BOX HFKC1
(14) BOX HFKC1
(50) DO NOT DISPLAY
(51) BOX HFKC1
(52) BOX HFKC1
(53) BOX HFKC1
(54) BOX HFKC1
(55) BOX HFKC1
(56) BOX HFKC1
(57) BOX HFKC1
(91) HFKB4_NEW - ROSTREOS
(-8) BOX HFKC1
(-9) BOX HFKC1
BOX HFKC1
(01) HFKC4 - PERSON_HLPRHHWK
(02) BOX HFKD1
(-8) BOX HFKD1
(-9) BOX HFKD1
doing heavy housework (like scrubbing floors or washing windows)?
Page 27 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
PERSON_HLPRHH
HFKC4
WK
roster
You mentioned that [you receive/(SP) receives] help with doing heavy housework (like scrubbing floors or
washing windows). Who gives that help?
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
HFKC4_NEW
HFKC4_NEW
ROSTREL
HFKC4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKC4_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFKD1
routing
IF HFKD1 – PRBMEAL = 1/Yes or HFKD2 – DONTMEAL = 1/Yes, GO TO HFKD3 - HELPMEAL.
ELSE GO TO BOX HFKE1.
[[You said that [your/(SP's)] health makes preparing [your/his/her] own meals difficult./You said that preparing
[your/his/her] own meals is something that [you don't do/(SP) doesn't do].]]
HELPMEAL
HFKD3
yes/no
[Do you/Does (SP)] receive help from another person with...
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
IF PERSON_HLPRHHWK = (N+1), GO TO
HFKC4_NEW-ROSTFNAM.
ELSE GO TO BOX HFKD1.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
HFKC4_NEW - ROSTLNAM
HFKC4_NEW - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX HFKD1
(03) BOX HFKD1
(04) BOX HFKD1
(05) BOX HFKD1
(06) BOX HFKD1
(07) BOX HFKD1
(08) BOX HFKD1
(09) BOX HFKD1
(10) BOX HFKD1
(11) BOX HFKD1
(12) BOX HFKD1
(13) BOX HFKD1
(14) BOX HFKD1
(50) DO NOT DISPLAY
(51) BOX HFKD1
(52) BOX HFKD1
(53) BOX HFKD1
(54) BOX HFKD1
(55) BOX HFKD1
(56) BOX HFKD1
(57) BOX HFKD1
(91) HFKC4_NEW - ROSTREOS
(-8) BOX HFKD1
(-9) BOX HFKD1
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
BOX HFKD1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFKD4 - PERSON_HLPRMEAL
(02) BOX HFKE1
(-8) BOX HFKE1
(-9) BOX HFKE1
preparing [your/his/her] own meals?
Page 28 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
PERSON_HLPRME
HFKD4
AL
roster
You mentioned that [you receive/(SP) receives] help with preparing [your/his/her] own meals. Who gives that
help?
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
HFKD4_NEW
HFKD4_NEW
ROSTREL
HFKD4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKD4_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFKE1
routing
IF HFKE1 – PRBSHOP = 1/Yes or HFKE2 – DONTSHOP = 1/Yes, GO TO HFKE3 - HELPSHOP.
ELSE GO TO BOX HFKF1.
[[You said that [your/(SP's)] health makes shopping for personal items (such as toilet items or medicines)
difficult./You said that shopping for personal items (such as toilet items or medicines) is something that [you
don't do/(SP) doesn't do].]]
HELPSHOP
HFKE3
yes/no
[Do you/Does (SP)] receive help from another person with...
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
IF PERSON_HLPRMEAL = (N+1), GO TO
HFKD4_NEW-ROSTFNAM.
ELSE GO TO BOX HFKE1.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
HFKD4_NEW - ROSTLNAM
HFKD4_NEW - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX HFKE1
(03) BOX HFKE1
(04) BOX HFKE1
(05) BOX HFKE1
(06) BOX HFKE1
(07) BOX HFKE1
(08) BOX HFKE1
(09) BOX HFKE1
(10) BOX HFKE1
(11) BOX HFKE1
(12) BOX HFKE1
(13) BOX HFKE1
(14) BOX HFKE1
(50) DO NOT DISPLAY
(51) BOX HFKE1
(52) BOX HFKE1
(53) BOX HFKE1
(54) BOX HFKE1
(55) BOX HFKE1
(56) BOX HFKE1
(57) BOX HFKE1
(91) HFKD4_NEW - ROSTREOS
(-8) BOX HFKE1
(-9) BOX HFKE1
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
BOX HFKE1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFKE4 - PERSON_HLPRSHOP
(02) BOX HFKF1
(-8) BOX HFKF1
(-9) BOX HFKF1
shopping for personal items (such as toilet items or medicines)?
Page 29 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
PERSON_HLPRSHO
HFKE4
P
roster
You mentioned that [you receive/(SP) receives] help with shopping for personal items (such as toilet items or
medicines). Who gives that help?
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
HFKE4_NEW
HFKE4_NEW
ROSTREL
HFKE4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKE4_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFKF1
routing
IF HFKF1- PRBBILS = 1/Yes or HFKF2 – DONTBILS = 1/Yes, GO TO HFKF3 - HELPBILS.
ELSE GO TO HFLINTRO - ADLSINTRO.
[[You said that [your/(SP's)] health makes managing money (like keeping track of expenses or paying bills)
difficult./You said that managing money (like keeping track of expenses or paying bills) is something that [you
don't do/(SP) doesn't do].]]
HELPBILS
HFKF3
yes/no
[Do you/Does (SP)] receive help from another person with...
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
IF PERSON_HLPRSHOP = (N+1), GO TO
HFKE4_NEW-ROSTFNAM.
ELSE GO TO BOX HFKF1.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
HFKE4_NEW - ROSTLNAM
HFKE4_NEW - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX HFKF1
(03) BOX HFKF1
(04) BOX HFKF1
(05) BOX HFKF1
(06) BOX HFKF1
(07) BOX HFKF1
(08) BOX HFKF1
(09) BOX HFKF1
(10) BOX HFKF1
(11) BOX HFKF1
(12) BOX HFKF1
(13) BOX HFKF1
(14) BOX HFKF1
(50) DO NOT DISPLAY
(51) BOX HFKF1
(52) BOX HFKF1
(53) BOX HFKF1
(54) BOX HFKF1
(55) BOX HFKF1
(56) BOX HFKF1
(57) BOX HFKF1
(91) HFKE4_NEW - ROSTREOS
(-8) BOX HFKF1
(-9) BOX HFKF1
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
BOX HFKF1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFKF4 - PERSON_HLPRBILS
(02) HFLINTRO - ADLSINTRO
(-8) HFLINTRO - ADLSINTRO
(-9) HFLINTRO - ADLSINTRO
managing money (like keeping track of expenses or paying bills)?
Page 30 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
PERSON_HLPRBILS HFKF4
roster
You mentioned that [you receive/(SP) receives] help with managing money (like keeping track of expenses or
paying bills). Who gives that help?
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
HFKF4_NEW
HFKF4_NEW
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
HFKF4_NEW - ROSTLNAM
HFKF4_NEW - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) HFLINTRO - ADLSINTRO
(03) HFLINTRO - ADLSINTRO
(04) HFLINTRO - ADLSINTRO
(05) HFLINTRO - ADLSINTRO
(06) HFLINTRO - ADLSINTRO
(07) HFLINTRO - ADLSINTRO
(08) HFLINTRO - ADLSINTRO
(09) HFLINTRO - ADLSINTRO
(10) HFLINTRO - ADLSINTRO
(11) HFLINTRO - ADLSINTRO
(12) HFLINTRO - ADLSINTRO
(13) HFLINTRO - ADLSINTRO
(14) HFLINTRO - ADLSINTRO
(50) DO NOT DISPLAY
(51) HFLINTRO - ADLSINTRO
(52) HFLINTRO - ADLSINTRO
(53) HFLINTRO - ADLSINTRO
(54) HFLINTRO - ADLSINTRO
(55) HFLINTRO - ADLSINTRO
(56) HFLINTRO - ADLSINTRO
(57) HFLINTRO - ADLSINTRO
(91) HFKF4_NEW - ROSTREOS
(-8) HFLINTRO - ADLSINTRO
(-9) HFLINTRO - ADLSINTRO
ROSTREL
HFKF4_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFKF4_NEW
text
[What is the name of the person and relationship to (SP)?]
ADLSINTRO
HFLINTRO
no entry
Remembering that health problems can include physical, mental, emotional, or memory problems, I'd now like
to ask you about how health problems may affect [your/(SP)'s] ability to perform some other everyday activities. (01) CONTINUE
I’d like to know whether [you have/(SP) has] any difficulty doing each activity by [yourself/himself/herself] and (-7) Empty
without special equipment.
Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty...
HPPDBATH
HFLA1
code 1
bathing or showering?
IF PERSON_HLPRBILS = (N+1), GO TO
HFKF4_NEW-ROSTFNAM.
ELSE GO TO HFLINTRO - ADLSINTRO.
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
HFLINTRO - ADLSINTRO
HFLA1 - HPPDBATH
(01) HFLB1 - HPPDDRES
(02) HFLB1 - HPPDDRES
(03) HFLA2 - DONTBATH
(-8) HFLB1 - HPPDDRES
(-9) HFLB1 - HPPDDRES
Page 31 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
[You said that bathing or showering is something that [you don't/(SP) doesn't] do.]
DONTBATH
HFLA2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDDRES
HFLB1
code 1
dressing?
[You said that dressing is something that [you don't/(SP) doesn't] do.]
DONTDRES
HFLB2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDEAT
HFLC1
code 1
eating?
[You said that eating is something that [you don't/(SP) doesn't] do.]
DONTEAT
HFLC2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDCHAR
HFLD1
code 1
getting in or out of bed or chairs?
[You said that getting in or out of bed or chairs is something that [you don't/(SP) doesn't] do.]
DONTCHAR
HFLD2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDWALK
HFLE1
code 1
walking?
[You said that walking is something that [you don't/(SP) doesn't] do.]
DONTWALK
HFLE2
code 1
Is this because of a physical, mental, emotional, or memory problem?
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDTOIL
HFLF1
code 1
using the toilet, including getting up and down?
[You said that using the toilet is something that [you don't/(SP) doesn't] do.]
DONTTOIL
HFLF2
yes/no
Is this because of a physical, mental, emotional, or memory problem?
HELPBATH
BOX HFLA1
routing
HFLA3
yes/no
[[You said [your/(SP's)] health makes bathing or showering difficult./You said that bathing or showering is
something [you don't/(SP) doesn't] do.]]
Does someone usually stay nearby just in case [you need/(SP) needs] help with bathing or showering?
HFLA4
HFLB1 - HPPDDRES
(01) HFLC1 - HPPDEAT
(02) HFLC1 - HPPDEAT
(03) HFLB2 - DONTDRES
(-8) HFLC1 - HPPDEAT
(-9) HFLC1 - HPPDEAT
HFLC1 - HPPDEAT
(01) HFLD1 - HPPDCHAR
(02) HFLD1 - HPPDCHAR
(03) HFLC2 - DONTEAT
(-8) HFLD1 - HPPDCHAR
(-9) HFLD1 - HPPDCHAR
HFLD1 - HPPDCHAR
(01) HFLE1 - HPPDWALK
(02) HFLE1 - HPPDWALK
(03) HFLD2 - DONTCHAR
(-8) HFLE1 - HPPDWALK
(-9) HFLE1 - HPPDWALK
HFLE1 - HPPDWALK
(01) HFLF1 - HPPDTOIL
(02) HFLF1 - HPPDTOIL
(03) HFLE2 - DONTWALK
(-8) HFLF1 - HPPDTOIL
(-9) HFLF1 - HPPDTOIL
HFLF1 - HPPDTOIL
(01) BOX HFLA1
(02) BOX HFLA1
(03) HFLF2 - DONTTOIL
(-8) BOX HFLA1
(-9) BOX HFLA1
BOX HFLA1
IF HFLA1 – HPPDBATH = 1/Yes OR HFLA2 - DONTBATH = 1/Yes, GO TO HFLA3 - HELPBATH.
ELSE GO TO BOX HFLB1.
[Do you/Does (SP)] receive help from another person with bathing or showering?
PCHKBATH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
yes/no
[That is, does someone usually stay or come into the room to check on [you/him/her]?]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFLA5 - EQIPBATH
(02) HFLA4 - PCHKBATH
(-8) HFLA4 - PCHKBATH
(-9) HFLA4 - PCHKBATH
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFLA5 - EQIPBATH
Page 32 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
EQIPBATH
Revised HFQ- Health Status and Functioning
HFLA5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with bathing or showering?
BOX HFLA2
routing
IF HFLA3 – HELPBATH = 1/Yes, GO TO HFLA6 - LONGBATH.
ELSE GO TO BOX HFLB1.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLA2
(01) HFLA7 - STILBATH
(02) BOX HFLB1
(03) BOX HFLB1
(-8) BOX HFLB1
(-9) BOX HFLB1
LONGBATH
HFLA6
code 1
How long [have you/has (SP)] needed help with bathing or showering? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
STILBATH
HFLA7
yes/no
Do you expect that [you/(SP)] will still need help with bathing or showering three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLB1
BOX HFLB1
routing
IF HFLB1 - HPPDDRES = 1/Yes OR HFLB2 – DONTDRES = 1/Yes, GO TO HFLB3 - HELPDRES.
ELSE GO TO BOX HFLC1.
HFLB3
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFLB5 - EQIPDRES
(02) HFLB4 - PCHKDRES
(-8) HFLB4 - PCHKDRES
(-9) HFLB4 - PCHKDRES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFLB5 - EQIPDRES
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLB2
(01) HFLB7 - STILDRES
(02) BOX HFLC1
(03) BOX HFLC1
(-8) BOX HFLC1
(-9) BOX HFLC1
HELPDRES
[[You said [your/(SP's)] health makes dressing difficult./You said that dressing is something [you don't/(SP)
doesn't] do.]]
[Do you/Does (SP)] receive help from another person with dressing?
Does someone usually stay nearby just in case [you need/(SP) needs] help with dressing?
PCHKDRES
HFLB4
yes/no
[That is, does someone usually stay or come into the room to check on [you/him/her]?]
EQIPDRES
HFLB5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with dressing?
BOX HFLB2
routing
IF HFLB3 – HELPDRES = 1/Yes, GO TO HFLB6 - LONGDRES.
ELSE GO TO BOX HFLC1.
LONGDRES
HFLB6
code 1
How long [have you/has (SP)] needed help with dressing? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
STILDRES
HFLB7
yes/no
Do you expect that [you/(SP)] will still need help with dressing three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLC1
BOX HFLC1
routing
IF HFLC1 - HPPDEAT = 1/Yes OR HFLC2 – DONTEAT = 1/Yes, GO TO HFLC3 - HELPEAT.
ELSE GO TO BOX HFLD1.
HFLC3
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFLC5 - EQIPEAT
(02) HFLC4 - PCHKEAT
(-8) HFLC4 - PCHKEAT
(-9) HFLC4 - PCHKEAT
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFLC5 - EQIPEAT
HELPEAT
[[You said [your/(SP's)] health makes eating difficult./You said that eating is something [you don't/(SP) doesn't]
do.]]
[Do you/Does (SP)] receive help from another person with eating?
Does someone usually stay nearby just in case [you need/(SP) needs] help with eating?
PCHKEAT
HFLC4
yes/no
[That is, does someone usually stay or come into the room to check on [you/him/her]?]
Page 33 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
EQIPEAT
Revised HFQ- Health Status and Functioning
HFLC5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with eating?
BOX HFLC2
routing
IF HFLC3 - HELPEAT = 1/Yes, GO TO HFLC6 - LONGEAT.
ELSE GO TO BOX HFLD1.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLC2
(01) HFLC7 - STILEAT
(02) BOX HFLD1
(03) BOX HFLD1
(-8) BOX HFLD1
(-9) BOX HFLD1
BOX HFLD1
LONGEAT
HFLC6
code 1
How long [have you/has (SP)] needed help with eating? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
STILEAT
HFLC7
yes/no
Do you expect that [you/(SP)] will still need help with eating three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLD1
routing
IF HFLD1 – HPPDCHAR = 1/Yes OR HFLD2 - DONTCHAR = 1/Yes, GO TO HFLD3 - HELPCHAR.
ELSE GO TO BOX HFLE1.
HELPCHAR
HFLD3
yes/no
[[You said [your/(SP's)] health makes getting in or out of bed or chairs difficult./You said that getting in or out of (01) YES
bed or chairs is something [you don't/(SP) doesn't] do.]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with getting in or out of bed or chairs?
(-9) Refused
PCHKCHAR
HFLD4
yes/no
Does someone usually stay nearby just in case [you need/(SP) needs] help with getting in or out of bed or chairs?
[That is, does someone usually stay or come into the room to check on (you/him/her)?]
EQIPCHAR
HFLD5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with getting in or out of bed or chairs?
BOX HFLD2
routing
IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD6 - LONGCHAR.
ELSE GO TO BOX HFLE1.
(01) HFLD5 - EQIPCHAR
(02) HFLD4 - PCHKCHAR
(-8) HFLD4 - PCHKCHAR
(-9) HFLD4 - PCHKCHAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFLD5 - EQIPCHAR
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLD2
(01) HFLD7 - STILCHAR
(02) BOX HFLE1
(03) BOX HFLE1
(-8) BOX HFLE1
(-9) BOX HFLE1
LONGCHAR
HFLD6
code 1
How long [have you/has (SP)] needed help with getting in or out of bed or chairs? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
STILCHAR
HFLD7
yes/no
Do you expect that [you/(SP)] will still need help with getting in or out of bed or chairs three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLE1
BOX HFLE1
routing
IF HFLE1- HPPDWALK = 1/Yes OR HFLE2 – DONTWALK = 1/Yes, GO TO HFLE3 - HELPWALK.
ELSE GO TO BOX HFLF1.
HFLE3
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFLE5 - EQIPWALK
(02) HFLE4 - PCHKWALK
(-8) HFLE4 - PCHKWALK
(-9) HFLE4 - PCHKWALK
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HFLE5 - EQIPWALK
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLE2
HELPWALK
[[You said [your/(SP's)] health makes walking difficult./You said that walking is something [you don't/(SP)
doesn't] do.]]
[Do you/Does (SP)] receive help from another person with walking?
Does someone usually stay nearby just in case [you need/(SP) needs] help with walking?
PCHKWALK
HFLE4
yes/no
[That is, does someone usually stay or come into the room to check on (you/him/her)?]
EQIPWALK
HFLE5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with walking?
Page 34 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
BOX HFLE2
routing
Revised HFQ- Health Status and Functioning
IF HFLE3 - HELPWALK = 1/Yes, GO TO HFLE6 - LONGWALK.
ELSE GO TO BOX HFLF1.
LONGWALK
HFLE6
code 1
How long [have you/has (SP)] needed help with walking? Has it been . . .
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
STILWALK
HFLE7
yes/no
Do you expect that [you/(SP)] will still need help with walking three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLF1
BOX HFLF1
routing
IF HFLF1 – HPPDTOIL = 1/Yes OR HFLF2 – DONTTOIL = 1/Yes, GO TO HFLF3 - HELPTOIL.
ELSE GO TO BOX HFLA3.
HFLF3
yes/no
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HFLF5 - EQIPTOIL
(02) HFLF4 - PCHKTOIL
(-8) HFLF4 - PCHKTOIL
(-9) HFLF4 - PCHKTOIL
HELPTOIL
[[You said [your/(SP's)] health makes using the toilet difficult./You said that using the toilet is something [you
don't/(SP) doesn't] do.]]
[Do you/Does (SP)] receive help from another person with using the toilet, including getting up and down?
PCHKTOIL
HFLF4
yes/no
Does someone usually stay nearby just in case [you need/(SP) needs] help with using the toilet, including getting (01) YES
up and down?
(02) NO
(-8) Don't Know
[That is, does someone usually stay or come into the room to check on [you/him/her]?]
(-9) Refused
EQIPTOIL
HFLF5
yes/no
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with using the toilet, including getting
up and down?
BOX HFLF2
routing
IF HFLF3 - HELPTOIL = 1/Yes, GO TO HFLF6 - LONGTOIL.
ELSE GO TO BOX HFLA3.
BOX HFLF2
(01) HFLF7 - STILTOIL
(02) BOX HFLA3
(03) BOX HFLA3
(-8) BOX HFLA3
(-9) BOX HFLA3
BOX HFLA3
LONGTOIL
HFLF6
code 1
How long [have you/has (SP)] needed help with using the toilet? Has it been . . .
STILTOIL
HFLF7
yes/no
Do you expect that [you/(SP)] will still need help with using the toilet three months from now?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HFLA3
routing
IF HFLA3 - HELPBATH = 1/Yes, GO TO HFLA9 - PERSON_HLPRBATH.
ELSE GO TO BOX HFLB3.
You mentioned that [you receive/(SP) receives] help with bathing and showering. Who gives that help?
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
roster
ENTER ALL HELPERS.
HFLF5 - EQIPTOIL
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused
PERSON_HLPRBAT
HFLA9
H
(01) HFLE7 - STILWALK
(02) BOX HFLF1
(03) BOX HFLF1
(-8) BOX HFLF1
(-9) BOX HFLF1
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
IF PERSON_HLPRBATH = (N+1) , GO TO
HFLA9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLB3.
Page 35 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
ROSTFNAM
ROSTLNAM
HFLA9_NEW
HFLA9_NEW
text
text
Revised HFQ- Health Status and Functioning
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
ROSTREL
HFLA9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLA9_NEW
text
[What is the name of the person and relationship to (SP)?]
routing
IF HFLB3 - HELPDRES = 1/Yes, GO TO HFLB9 - PERSON_HLPRDRES.
ELSE GO TO BOX HFLC3.
BOX HFLB3
You mentioned that [you receive/(SP) receives] help with dressing. Who gives that help?
PERSON_HLPRDRE
HFLB9
S
roster
ROSTFNAM
ROSTLNAM
text
text
HFLB9_NEW
HFLB9_NEW
ENTER ALL HELPERS.
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
HFLA9_NEW - ROSTLNAM
HFLA9_NEW - ROSTREL
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) DO NOT DISPLAY
(02) BOX HFLB3
(03) BOX HFLB3
(04) BOX HFLB3
(05) BOX HFLB3
(06) BOX HFLB3
(07) BOX HFLB3
(08) BOX HFLB3
(09) BOX HFLB3
(10) BOX HFLB3
(11) BOX HFLB3
(12) BOX HFLB3
(13) BOX HFLB3
(14) BOX HFLB3
(50) DO NOT DISPLAY
(51) BOX HFLB3
(52) BOX HFLB3
(53) BOX HFLB3
(54) BOX HFLB3
(55) BOX HFLB3
(56) BOX HFLB3
(57) BOX HFLB3
(91) HFLA9_NEW - ROSTREOS
(-8) BOX HFLB3
(-9) BOX HFLB3
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
BOX HFLB3
IF PERSON_HLPRBATH = (N+1), GO TO
HFLB9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLC3.
HFLB9_NEW - ROSTLNAM
HFLB9_NEW - ROSTREL
Page 36 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
ROSTREL
HFLB9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLB9_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFLC3
routing
IF HFLC3 – HELPEAT = 1/Yes, GO TO HFLC9 - PERSON_HLPREAT.
ELSE GO TO BOX HFLD3.
You mentioned that [you receive/(SP) receives] help with eating. Who gives that help?
PERSON_HLPREAT HFLC9
roster
ENTER ALL HELPERS.
ROSTFNAM
ROSTLNAM
HFLC9_NEW
HFLC9_NEW
text
text
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) DO NOT DISPLAY
(02) BOX HFLC3
(03) BOX HFLC3
(04) BOX HFLC3
(05) BOX HFLC3
(06) BOX HFLC3
(07) BOX HFLC3
(08) BOX HFLC3
(09) BOX HFLC3
(10) BOX HFLC3
(11) BOX HFLC3
(12) BOX HFLC3
(13) BOX HFLC3
(14) BOX HFLC3
(50) DO NOT DISPLAY
(51) BOX HFLC3
(52) BOX HFLC3
(53) BOX HFLC3
(54) BOX HFLC3
(55) BOX HFLC3
(56) BOX HFLC3
(57) BOX HFLC3
(91) HFLB9_NEW - ROSTREOS
(-8) BOX HFLC3
(-9) BOX HFLC3
BOX HFLC3
IF PERSON_HLPREAT = (N+1) GO TO
HFLC9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLD3.
HFLC9_NEW - ROSTLNAM
HFLC9_NEW - ROSTREL
Page 37 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
ROSTREL
HFLC9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLC9_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFLD3
routing
IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD9 - PERSON_HLPRCHAR.
ELSE GO TO BOX HFLE3.
You mentioned that [you receive/(SP) receives] help with getting in or out of bed or chairs. Who gives that help?
PERSON_HLPRCHA
HFLD9
R
roster
ROSTFNAM
ROSTLNAM
text
text
HFLD9_NEW
HFLD9_NEW
ENTER ALL HELPERS.
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) DO NOT DISPLAY
(02) BOX HFLD3
(03) BOX HFLD3
(04) BOX HFLD3
(05) BOX HFLD3
(06) BOX HFLD3
(07) BOX HFLD3
(08) BOX HFLD3
(09) BOX HFLD3
(10) BOX HFLD3
(11) BOX HFLD3
(12) BOX HFLD3
(13) BOX HFLD3
(14) BOX HFLD3
(50) DO NOT DISPLAY
(51) BOX HFLD3
(52) BOX HFLD3
(53) BOX HFLD3
(54) BOX HFLD3
(55) BOX HFLD3
(56) BOX HFLD3
(57) BOX HFLD3
(91) HFLC9_NEW - ROSTREOS
(-8) BOX HFLD3
(-9) BOX HFLD3
BOX HFLD3
IF PERSON_HLPRCHAR = (N+1) , GO TO
HFLD9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLE3.
HFLD9_NEW - ROSTLNAM
HFLD9_NEW - ROSTREL
Page 38 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
ROSTREL
HFLD9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLD9_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFLE3
routing
IF HFLE3 – HELPWALK = 1/Yes, GO TO HFLE9 - PERSON_HLPRWALK.
ELSE GO TO BOX HFLF3.
You mentioned that [you receive/(SP) receives] help with walking. Who gives that help?
PERSON_HLPRWA
HFLE9
LK
roster
ROSTFNAM
ROSTLNAM
text
text
HFLE9_NEW
HFLE9_NEW
ENTER ALL HELPERS.
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) DO NOT DISPLAY
(02) BOX HFLE3
(03) BOX HFLE3
(04) BOX HFLE3
(05) BOX HFLE3
(06) BOX HFLE3
(07) BOX HFLE3
(08) BOX HFLE3
(09) BOX HFLE3
(10) BOX HFLE3
(11) BOX HFLE3
(12) BOX HFLE3
(13) BOX HFLE3
(14) BOX HFLE3
(50) DO NOT DISPLAY
(51) BOX HFLE3
(52) BOX HFLE3
(53) BOX HFLE3
(54) BOX HFLE3
(55) BOX HFLE3
(56) BOX HFLE3
(57) BOX HFLE3
(91) HFLD9_NEW - ROSTREOS
(-8) BOX HFLE3
(-9) BOX HFLE3
BOX HFLE3
IF PERSON_HLPRWALK = (N+1), GO TO
HFLE9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLF3.
HFLE9_NEW - ROSTLNAM
HFLE9_NEW - ROSTREL
Page 39 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
ROSTREL
HFLE9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLE9_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFLF3
routing
IF HFLF3 – HELPTOIL = 1/Yes, GO TO HFLF9 - PERSON_HLPRTOIL.
ELSE GO TO BOX HFL4.
You mentioned that [you receive/(SP) receives] help with using the toilet. Who gives that help?
PERSON_HLPRTOI
HFLF9
L
roster
ROSTFNAM
ROSTLNAM
text
text
HFLF9_NEW
HFLF9_NEW
ENTER ALL HELPERS.
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) DO NOT DISPLAY
(02) BOX HFLF3
(03) BOX HFLF3
(04) BOX HFLF3
(05) BOX HFLF3
(06) BOX HFLF3
(07) BOX HFLF3
(08) BOX HFLF3
(09) BOX HFLF3
(10) BOX HFLF3
(11) BOX HFLF3
(12) BOX HFLF3
(13) BOX HFLF3
(14) BOX HFLF3
(50) DO NOT DISPLAY
(51) BOX HFLF3
(52) BOX HFLF3
(53) BOX HFLF3
(54) BOX HFLF3
(55) BOX HFLF3
(56) BOX HFLF3
(57) BOX HFLF3
(91) HFLE9_NEW - ROSTREOS
(-8) BOX HFLF3
(-9) BOX HFLF3
BOX HFLF3
IF PERSON_HLPRTOIL = (N+1), GO TO
HFLF9_NEW-ROSTFNAM.
ELSE GO TO BOX HFLG3.
HFLF9_NEW - ROSTLNAM
HFLF9_NEW - ROSTREL
Page 40 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
ROSTREL
HFLF9_NEW
code one
[What is the name of the person and relationship to (SP)?]
ROSTREOS
HFLF9_NEW
text
[What is the name of the person and relationship to (SP)?]
BOX HFL4
routing
IF MORE THAN ONE PERSON SELECTED AT HFLA9, HFLB9, HFLC9, HFLD9, HFLE9, AND/OR HFLF9, GO TO HFL10 PERSON_HLPRMOST.
ELSE GO TO HFM1 - FALLANY.
Which of these persons gives [you/(SP)] the most help with these things?
PERSON_HLPRMO
HFL10
ST
roster
ROSTFNAM
ROSTLNAM
text
text
HFL10_NEW
HFL10_NEW
SELECT ONLY ONE.
[What is the name of the person and relationship to (SP)?]
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
(01) DO NOT DISPLAY
(02) BOX HFLF3
(03) BOX HFLF3
(04) BOX HFLF3
(05) BOX HFLF3
(06) BOX HFLF3
(07) BOX HFLF3
(08) BOX HFLF3
(09) BOX HFLF3
(10) BOX HFLF3
(11) BOX HFLF3
(12) BOX HFLF3
(13) BOX HFLF3
(14) BOX HFLF3
(50) DO NOT DISPLAY
(51) BOX HFLF3
(52) BOX HFLF3
(53) BOX HFLF3
(54) BOX HFLF3
(55) BOX HFLF3
(56) BOX HFLF3
(57) BOX HFLF3
(91) HFLF9_NEW - ROSTREOS
(-8) BOX HFLF3
(-9) BOX HFLF3
BOX HFLF3
IF PERSON_HLPRMOST = (N+1), GO TO
HFLF10_NEW-ROSTFNAM.
ELSE GO TO HFM1 - FALLANY.
HFLF10_NEW - ROSTLNAM
HFLF10_NEW - ROSTREL
Page 41 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
ROSTREL
HFL10_NEW
code one
ROSTREOS
HFL10_NEW
text
FALLANY
HFM1
yes/no
FALLTIME
HFM2
numeric
FALLHELP
HFM3A
yes/no
FALCODE
HFM3B
code all
FALOTHOS
HFM3B
verbatim text
FALLIMIT
HFM3C
yes/no
FALLBACK
HFM3D
code 1
Revised HFQ- Health Status and Functioning
[What is the name of the person and relationship to (SP)?]
(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused
(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] fallen down?
(-8) Don't Know
(-9) Refused
Since (LAST HF MONTH YEAR), how many times [have you/has (SP)] fallen down?
[Continuous answer.]
Don't Know
ENTER "95" IF 95 OR MORE FALLS REPORTED.
Refused
(01) YES
Thinking about the [most recent) time that [you/(SP)] fell, did [you/he/she] hurt [yourself/himself/herself] badly (02) NO
enough to get medical help?
(-8) Don't Know
(-9) Refused
(01) BROKEN BONE/FRACTURE
(02) SPRAIN/STRAIN
(03) BRUISE
What kind of injury did [you/(SP)] have in that [most recent] fall?
(04) CUT/WOUND/LACERATION
(05) CONCUSSION
[PROBE: Anything else?]
(06) DISLOCATION
(91) OTHER
CHECK ALL THAT APPLY.
(96) NO INJURY
(-8) Don't Know
(-9) Refused
OTHER (SPECIFY)
(01) [Continuous answer.]
(01) YES
(02) NO
Did [your/(SP's)] [most recent] fall cause [you/him/her] to limit [your/his/her] regular acivities?
(-8) Don't Know
(-9) Refused
(01) LESS THAN ONE WEEK
(02) ONE WEEK OR MORE
(03) NEVER RESUMED REGULAR ACTIVITIES
How long did it take [you/(SP)] to get back to regular activities after [your/his/her] [most recent] fall?
(-8) Don't Know
(-9) Refused
[What is the name of the person and relationship to (SP)?]
(01) DO NOT DISPLAY
(02) HFM1 - FALLANY
(03) HFM1 - FALLANY
(04) HFM1 - FALLANY
(05) HFM1 - FALLANY
(06) HFM1 - FALLANY
(07) HFM1 - FALLANY
(08) HFM1 - FALLANY
(09) HFM1 - FALLANY
(10) HFM1 - FALLANY
(11) HFM1 - FALLANY
(12) HFM1 - FALLANY
(13) HFM1 - FALLANY
(14) HFM1 - FALLANY
(50) DO NOT DISPLAY
(51) HFM1 - FALLANY
(52) HFM1 - FALLANY
(53) HFM1 - FALLANY
(54) HFM1 - FALLANY
(55) HFM1 - FALLANY
(56) HFM1 - FALLANY
(57) HFM1 - FALLANY
(91) HFLF10_NEW - ROSTREOS
(-8) HFM1 - FALLANY
(-9) HFM1 - FALLANY
HFM1 - FALLANY
(01) HFM2 - FALLTIME
(02) BOX MH1
(-8) BOX MH1
(-9) BOX MH1
HFM3A - FALLHELP
HFM3B - FALCODE
(01) HFM3C - FALLIMIT
(02) HFM3C - FALLIMIT
(03) HFM3C - FALLIMIT
(04) HFM3C - FALLIMIT
(05) HFM3C - FALLIMIT
(06) HFM3C - FALLIMIT
(91) HFM3B - FALOTHOS
(96) HFM3C - FALLIMIT
(-8) HFM3C - FALLIMIT
(-9) HFM3C - FALLIMIT
HFM3C - FALLIMIT
(01) HFM3D - FALLBACK
(02) HFM3E - FALLFEAR
(-8) HFM3E - FALLFEAR
(-9) HFM3E - FALLFEAR
HFM3E - FALLFEAR
Page 42 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
FALLFEAR
HFM3E
BOX MH1
numeric
routing
Revised HFQ- Health Status and Functioning
How would you rate [your/(SP's)] fear of falling on a scale of 1 to 6, where 1 is "Not at all afraid of falling" and 6
is "Extremely afraid of falling"?
If the respondent is a proxy (SPPROXY=2), go to HFQ1 - LOSTURIN.
Else go to HFN1 - HFGAD1.
The next few questions ask about the last two weeks.
SHOW CARD HF8
HFGAD1
HFN1
list
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge
SHOW CARD HF8
HFGAD2
HFN2
list
[Over the last 2 weeks, how often have you been bothered by the following problems?]
Not being able to stop or control worrying.
SHOW CARD HF8
HFPHQ1
HFN3
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
little interest or pleasure in doing things? Would you say…
SHOW CARD HF8
HFPHQ2
HFN4
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling down, depressed, or hopeless?
SHOW CARD HF8
HFPHQ3
HFN5
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble falling or staying asleep, or sleeping too much?
SHOW CARD HF8
HFPHQ4
HFN6
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling tired or having little energy?
SHOW CARD HF8
HFPHQ5
HFN7
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
poor appetite or overeating?
SHOW CARD HF8
HFPHQ6
HFN8
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling bad about yourself – or that you are a failure or have let yourself or your family down?
SHOW CARD HF8
HFPHQ7
HFN9
list
[Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble concentrating on things, such as reading the newspaper or watching TV?
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW
BOX MH1
HFN2 - HFGAD2
HFN3 - HFPHQ1
HFN4 - HFPHQ2
HFN5 - HFPHQ3
HFN6 - HFPHQ4
HFN7 - HFPHQ5
HFN8 - HFPHQ6
HFN9 - HFPHQ7
HFN10 - HFPHQ8
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SHOW CARD HF8
HFPHQ8
HFN10
list
HFPHQ10
HFN11
code one
LOSTURIN
HFQ1
code 1
TALKURIN
HFQ2
yes/no
FEELURIN
HFQ3
yes/no
REASURIN
HFQ4
yes/no
SURGURIN
HFQ5
yes/no
BOX HFT1
routing
HYPETOLD
HFT1
code 1
HYPEAGE
HFT2
numeric
HYPEAGE_LESSON
HFT2
E
numeric
HYPEHOME
HFT6D
yes/no
HYPEMEDS
HFT6G
yes/no
(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or
(-8) REFUSED
restless that you have been moving around a lot more than usual?
(-9) DON’T KNOW
(01) Not at all difficult,
SHOW CARD HF9
(02) Somewhat difficult,
(03) Very difficult,
How difficult have these problems made it for you to do your work, take care of things at home, or get along
(04) Extremely difficult?
with people?
(-8) REFUSED
(-9) DON’T KNOW
(01) MORE THAN ONCE A WEEK
(02) ABOUT ONCE A WEEK
(03) 2-3 TIMES A MONTH
SHOW CARD HF10
(04) ABOUT ONCE A MONTH
(05) EVERY 2-3 MONTHS
I'd like to ask about a health problem that is more common than people think. Please look at this card and tell
(06) ONCE OR TWICE A YEAR
me how often, if at all, since (LAST HF MONTH YEAR) [you have/(SP) has] lost urine because [you/he/she] could (07) NOT AT ALL
not control [your/his/her] bladder.
(08) SP IS ON DIALYSIS OR CATHETERIZATION OR
UROSTOMY OR BLADDER BAG
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
[Have you/Has (SP)] talked about this problem with [your/(SP’s)] doctor or other health professional?
(-8) Don't Know
(-9) Refused
(01) YES
Has [your/(SP’s)] doctor or other health professional asked [you/him/her] about how [you/he/she] feel[s] about (02) NO
this problem?
(-8) Don't Know
(-9) Refused
(01) YES
Has [your/(SP’s)] doctor or other health professional examined [you/him/her] to figure out why [you/he/she]
(02) NO
[lose/loses] urine?
(-8) Don't Know
(-9) Refused
(01) YES
Has [your/(SP’s)] doctor or other health professional talked with [you/him/her] about taking medicine or having (02) NO
surgery for this problem?
(-8) Don't Know
(-9) Refused
IF HFJ2 - OCHBP = 1/Yes, GO TO HFT1 - HYPETOLD.
ELSE GO TO BOX HFEND.
We have recorded that [you were/(SP) was] told by a doctor or other health professional that [you had/he
(01) YES
had/she had] hypertension, also called high blood pressure.
(02) NO
[Were you/Was (SP)] told on two or more different medical visits that [you/he/she] had high blood pressure or (03) SP NEVER HAD HIGH BLOOD PRESSURE/PREVIOUS
RESPONSE ENTERED IN ERROR
hypertension?
(-8) Don't Know
[EXPLAIN IF NECESSARY: We are interested in knowing whether [your/(SP’s)] blood pressure was high for more (-9) Refused
than one reading.]
(01) [Continuous answer.]
How old [were you/was (SP)] when [you were/he was/she was] first told that [you/he/she] had high blood
(-8) Don't Know
pressure?
(-9) Refused
[Over the last 2 weeks, how often have you been bothered by the following problems:]
How old [were you/was (SP)] when (you were/he was/she was) first told that [you/he/she] had high blood
pressure?
(01) LESS THAN ONE YEAR OLD
(-7) Empty
(01) YES
Because of [your/his/her] high blood pressure, [are you/is (SP)] now measuring [your/his/her] blood pressure at (02) NO
(-8) Don't Know
home?
(-9) Refused
(01) YES
(02) NO
Because of [your/his/her] high blood pressure, [are you/is (SP)] now taking prescribed medicine for
(-8) Don't Know
[your/his/her] high blood pressure?
(-9) Refused
HFN11 - HFPHQ10
HFQ1 - LOSTURIN
(01) HFQ2 - TALKURIN
(02) HFQ2 - TALKURIN
(03) HFQ2 - TALKURIN
(04) HFQ2 - TALKURIN
(05) HFQ2 - TALKURIN
(06) HFQ2 - TALKURIN
(07) BOX HFT1
(08) BOX HFT1
(-8) BOX HFT1
(-9) BOX HFT1
(01) HFQ3 - FEELURIN
(02) BOX HFT1
(-8) BOX HFT1
(-9) BOX HFT1
HFQ4 - REASURIN
HFQ5 - SURGURIN
BOX HFT1
(01) HFT2 - HYPEAGE
(02) HFT2 - HYPEAGE
(03) BOX HFEND
(-8) HFT2 - HYPEAGE
(-9) HFT2 - HYPEAGE
HFT2 - HYPEAGE_LESSONE
HFT6D - HYPEHOME
HFT6G - HYPEMEDS
HFT6J - HYPEDRNK
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HFT6J
yes/no
[Have you/Has (SP)] cut down on drinking alcoholic beverages because of [your/his/her] high blood pressure?]
BOX HFT2
routing
IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT7 - HYPELONG.
ELSE GO TO HFT12A - HYPECTRL.
HFT7
numeric
How long [have you/has (SP)] been treated with prescribed medicines for [your/his/her] high blood pressure?
HYPELONG_LESSO
HFT7
NE
numeric
How long [have you/has (SP)] been treated with prescribed medicines for [your/his/her] high blood pressure?
BOX HFT3
routing
IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFT8 - HYPEMANY.
ELSE GO TO HFT11A - HYPECOND.
HFT8
numeric
HYPELONG
How many different prescribed medicines [do you/does (SP)] take for [your/his/her] high blood pressure?
HYPEMANY
[WE ARE ASKING ABOUT HOW MANY DIFFERENT PRESCRIBED MEDICINES FOR HIGH BLOOD PRESSURE ARE
TAKEN BY THE RESPONDENT, NOT THE NUMBER OF PILLS THEY MIGHT TAKE IN ONE DAY.]
How often [do you/does (SP)] have trouble with side effects from [your/his/her] blood pressure medicines[s]?
Please tell me if [you/he/she] always, sometimes, or never [have/has] trouble with side effects.
HYPECOND
HFT11A
code 1
[EXPLAIN IF NECESSARY: By "side effects", I mean that the medicine causes any condition such as fatigue,
headache, or coughing.]
HYPECTRL
HFT12A
code 1
Doctors and other health professionals often recommend changing your habits or lifestyle, such as changing
your diet, or getting regular exercise in order to control blood pressure. How confident are you that [you/(SP)]
can follow these recommendation?
Would you say that you are very confident, confident, somewhat confident, or not at all confident?
BOX HFT4
routing
IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT13 - HYPEPAY.
ELSE GO TO BOX HFEND.
HYPEPAY
HFT13
yes/no
[Do you/Does (SP)] have difficulty paying for the medicine[s] [your/his/her] doctor or other health professional
prescribes for [your/his/her] high blood pressure?
HYPESKIP
HFT14
yes/no
[Do you/Does (SP)] ever skip taking [your/his/her] medicine, take less medicine than prescribed, or share
medicine because of the cost of the medicine?
BOX HFT5
routing
If Respondent is SP, go to CNINTRO-CNINTRO
Else, If Respondent it Proxy, go to BOX HFEND
CNINTRO
no entry
CNINTRO
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
(01) LESS THAN ONE YEAR
(-7) Empty
BOX HFT2
HFT7 - HYPELONG_LESSONE
BOX HFT3
(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused
HFT11A - HYPECOND
(01) ALWAYS
(02) SOMETIMES
(03) NEVER
(-8) Don't Know
(-9) Refused
HFT12A - HYPECTRL
(01) VERY CONFIDENT
(02) CONFIDENT
(03) SOMEWHAT CONFIDENT
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
(-9) Refused
BOX HFT4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
Now I'd like to ask you some questions having to do with memory. The questions may seem unusual, but they
are routine questions we ask everyone. Some of the questions are very easy and some are difficult, so don’t be Continue
surprised if you have trouble with some of them. Try your best to answer all of the questions without using clues
from around the room. If you wear glasses for reading, please use them.
HFT14 - HYPESKIP
BOX HFT5
CNTTM20
For the first question, please try to count backward as quickly as you can from the number I will give you. I will
tell you when to stop.
CNTTM20
CNTTM20
numeric
ALLOW R TO START OVER IF S/HE WISHES TO DO SO
Please start with: 20
(1) CONTINUOUS
(-8) DON'T KNOW
(-9) REFUSED
(1) CNTOTCM1
(-8) TDYMTH
(-9) TDYMTH
CORRECT RESPONSES INCLUDE COUNTING DOWN FROM 19 TO 10 OR FROM 20 TO 11
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You may stop now. Thank you.
CNTOTCM1
CNTOTCM1
code one
CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR
ALLOW R TO START OVER IF S/HE WISHES TO DO SO
Let's try again.
CNTTMT2
CNTTMT2
numeric
The number to count backward from is: 20
You may stop now. Thank you.
CNTOTCM2
CNTOTCM2
code one
CODE CORRECT IF R COUNTED BACKWARDS FROM 19 TO 10 OR FROM 20 TO 11 WITHOUT ERROR
Please tell me today's date.
TDYMTH
TDYMTH
code one
PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
Please tell me today's date.
TDYDAY
TDYMTH
code one
PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
Please tell me today's date.
TDYYEAR
TDYMTH
code one
PROBE MONTH, DAY, YEAR, DAY OF WEEK
THE DATE IS: MONTH/DAY/YEAR
What is the day of the week?
TDYDOW
TDYDOW
code one
THE DAY OF THE WEEK IS: DAY OF WEEK
SCISSOR
SCISSOR
code one
Now I'm going to ask you for the names of some people and things.
What do people usually use to cut paper?
CACTUS
CACTUS
code one
What do you call the kind of prickly plant that grows in the desert?
(1) CORRECT
(2) INCORRECT
(3) WANTS TO START OVER
(-9) REFUSED
(1) TDYMTH
(2) TDYMTH
(3) CNTTMT2
(-9) TDYMTH
(1) CONTINUOUS
(-8) DON'T KNOW
(-9) REFUSED
CNTOTCM2
(1) CORRECT
(2) INCORRECT
(-9) REFUSED
TDYMTH
(1) MONTH CORRECT
(2) MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
TDYDAY
(1) DAY OF MONTH CORRECT
(2) DAY OF MONTH NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
TDYYEAR
(1) YEAR CORRECT
(2) YEAR NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
TDYDOW
(1) DAY CORRECT
(2) DAY NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
(1) SCISSORS OR SHEARS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
(1) CACTUS OR NAME OF KIND OF CACTUS
(2) NOT CORRECT
(-8) DON'T KNOW
(-9) REFUSED
SCISSOR
CACTUS
POTUS
Who is the President of the United States right now?
ANSWER IS TRUMP
(1) LAST NAME CORRECT
(2) NOT CORRECT
IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is important (-8) DON'T KNOW
to understanding whether the needs of beneficiaries are being met and for measuring the impact on current and (-9) REFUSED
future health care costs.
PROBE FOR LAST NAME
POTUS
POTUS
code one
VPOTUS
IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey will
not collect any information about your political affiliation.
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Who is Vice President?
ANSWER IS PENCE
PROBE FOR LAST NAME
VPOTUS
VPOTUS
code one
(1) LAST NAME CORRECT
(2) NOT CORRECT
IF NEEDED: These questions have to do with memory. Assessing memory in the Medicare population is important (-8) DON'T KNOW
to understanding whether the needs of beneficiaries are being met and for measuring the impact on current and (-9) REFUSED
future health care costs.
PHYSINTRO-PHYSINTRO
IF NEEDED: NORC at the University of Chicago is an objective, non-partisan research institution. This survey will
not collect any information about your political affiliation.
IF R IS IN A WHEELCHAIR OR CANNOT STAND, SELECT "(02) R CANNOT PARTICIPATE" WITHOUT READING TEXT
BELOW.
Now I am going to ask you to do a few simple activities. Researchers are
interested in how performance on these activities relates to some of the other factors I
have asked you about in the interview.
PHYSINTRO
PHYSINTRO
no entry
I will ask you to do these activities: height and weight measurements, a balance test, a walking test, and a
standing test.[, and a test of hand strength.]
(01) CONTINUE
(02) R CANNOT PARTICIPATE (IN WHEELCHAIR, CAN’T
STAND)
(01) BALINTRO HGTINTRO
(02) BOX HFEND
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
(01) HGTMEASU
(02) HGTREASN
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
(01) WGTINTRO
(996) HGTREASN
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) - (06), (-8), (-9) WGTINTRO
(91) HGTREAOS
(01) Continuous answer
WGTINTRO
My primary concern is for your safety, so I will ask you if you feel it would be safe for
you to complete each activity. I will describe these measurements and ask if you would feel comfortable and
safe completing each of the measurements. We will then complete the measurements one after the other.
Let's start by measuring your height.
HGTINTRO
HGTINTRO
code one
I will ask you to stand up straight against the wall with your feet together. Then, I will mark your height on the
wall using a sticky note and ask you to step away. I will then measure from the sticky note to the floor.
Is there any reason why you feel you cannot participate?
[IF R REFUSES TO ATTEMPT THE MEASURE, CODE (02) R CANNOT OR WILL NOT PARTICIATE]
HGTMEASU
HGTMEASU
verbatim text
RECORD HEIGHT TO THE NEAREST HALF-INCH.
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED.
HGTREASN
HGTREASN
code one
[IF THE RESPONDENT REFUSED TO ATTEMPT THE MEASURE, SELECT "REFUSED."]
HGTREAOS
HGTREAOS
verbatim text
WHAT IS THE PRIMARY REASON THE RESPONDENT CANNOT OR WILL NOT PARTICIPATE IN THIS MEASURE?
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Now, we will measure your weight.
WGTINTRO
WGTINTRO
code one
I will ask you to stand on the scale and stand still. Once I have recorded the weight, I will ask you to step off of
the scale.
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
(01) WGTMEASU
(02) WGTREASN
Is there any reason why you feel you cannot participate?
[IF R REFUSES TO ATTEMPT THE MEASURE, CODE (02) R CANNOT OR WILL NOT PARTICIATE]
WGTMEASU
WGTMEASU
verbatim text
RECORD WEIGHT TO THE NEAREST TENTH OF A POUND
(01) continuous answer
(996) TEST COULD NOT BE COMPLETED
(01) BALINTRO
(996) WGTREASN
(01) - (06), (-8), (-9) BALINTRO
(91) WGTEXCLD
WGTREASN
WGTREASN
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED.
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
WGTEXCLD
WGTEXCLD
verbatim text
WHAT IS THE PRIMARY REASON THE RESPONDENT CANNOT OR WILLNOT PARTICIPATE IN THIS MEASURE?
(01) Continuous answer
BALINTRO
no entry
Next I am going to ask you to do a few simple activities for me, starting with a balance measure. Let me first
demonstrate this measure. After I demonstrate the measure, please tell me if you cannot do a particular
movement or if you feel it would be unsafe to try and do it.
(01) CONTINUE
(02) R CANNOT OR WILL NOT PARTICIPATE
(01) BALPOS1
(02) BALREAS1
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
If (1) >= 10 seconds, go to BALPOS2;
(996) BALREAS1
BALINTRO
BALINTRO
[IF R REFUSES TO ATTEMPT THE MEASURE, CODE (02) R CANNOT OR WILL NOT PARTICIATE]
SHOWCARD PM1
DEMONSTRATE FIRST POSITION WHILE EXPLAINING POSITION
STAND WITH FEET TOGETHER, SIDE-BY-SIDE FOR 10 SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN FIRST POSITION
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
BALPOS1
BALPOS1
code one
TIME THE FIRST POSITION
PUSH ‘START/STOP’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘START/STOP’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘START/STOP’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION BEFORE 10 SECONDS
WHEN R IS IN FIRST POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START/STOP’ AND SAY:
Begin
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BALREAS1
BALREAS1
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
BALREOS1
BALREOS1
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
WALINTRO
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
If (1) >= 10 seconds, go to BALPOS3;
(996) BALREAS2
(01)-(06), (-8), (-9) WALINTRO
(91) BALPOSOS2
WALINTRO
(01)-(06), (-8), (-9) WALINTRO
(91) BALPOSOS1
SHOWCARD PM2
DEMONSTRATE SECOND POSITION WHILE EXPLAINING POSITION
STAND WITH THE HEEL OF ONE FOOT TOUCHING THE SIDE OF THE BIG TOE OF THE OTHER FOOT FOR 10
SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN SECOND POSITION
BALPOS2
BALPOS2
code one
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
TIME THE SECOND POSITION
PUSH ‘START/STOP’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘START/STOP’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘START/STOP’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION BEFORE 10 SECONDS
WHEN R IS IN SECOND POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START/STOP’ AND SAY:
Begin
BALREAS2
BALREAS2
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
BALREOS2
BALREOS2
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
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SHOWCARD PM3
DEMONSTRATE THIRD POSITION WHILE EXPLAINING POSITION
STAND WITH THE HEEL OF ONE FOOT IN FRONT OF AND TOUCHING THE TOES OF THE OTHER FOOT FOR 10
SECONDS
TRY NOT TO MOVE YOUR FEET
TRY TO HOLD THIS POSITION UNTIL I TELL YOU TO STOP
ASK R TO STAND IN THIRD POSITION
BALPOS3
BALPOS3
code one
ONCE R IS IN POSITION, SAY ‘BEGIN’ AND START TIMING
(01) NUMBER OF SECONDS HELD: _____
[996] TEST COULD NOT BE COMPLETED
(01)-(06), (-8), (-9) WALINTRO
(91) BALPOSOS3
(01)-(06), (-8), (-9) WALINTRO
(91) BALPOSOS3
WALINTRO
TIME THE THIRD POSITION
PUSH ‘START/STOP’ BUTTON WHEN YOU SAY ‘BEGIN’
PUSH ‘START/STOP’ BUTTON AND SAY ‘STOP’ AFTER 10 SECONDS, OR
PUSH ‘START/STOP’ BUTTON IF RESPONDENT STEPS OUT OF THE POSITION BEFORE 10 SECONDS
WHEN R IS IN THIRD POSITION:
Are you ready?
WHEN R IS READY, PUSH ‘START/STOP’ AND SAY:
Begin
BALREAS3
BALREAS3
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
BALREOS3
BALREOS3
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
Now I am going to observe how you normally walk. If you use a cane or other walking aid and you feel you need
it to walk a short distance, then you may use it. First, let me demonstrate this measure.
WALINTRO
WALINTRO
no entry
(01) CONTINUE
After I demonstrate the measure, please tell me if you cannot do a particular movement or if you feel it would be
(02) R CANNOT OR WILL NOT PARTICIPATE
unsafe to try and do it.
(01) WALKTIM1
(02) WALKREAS1
[IF R REFUSES TO ATTEMPT THE MEASURE, CODE (02) R CANNOT OR WILL NOT PARTICIATE]
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USE PRE-CUT STRING TO MEASURE DISTANCE ON THE FLOOR
DEMONSTRATE THE WALK WHILE PROVIDING INSTRUCTIONS
STAND WITH TOES TOUCHING THE BEGINNING OF THE STRING
START WALKING WHEN I SAY BEGIN
WALK AT YOUR USUAL PACE
WALK PAST THE END OF THE STRING BEFORE YOU STOP
WALKTIM1
WALKTIM1
code one
ALLOW R TO USE HIS/HER WALKING AID (CANE OR WALKER)
(01) ABLE TO DO (SPECIFY SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
(01) WALKTIM2
(996) WALKREAS1
(01)-(06), (-8), (-9) CSINTRO
(91) WALKOS1
ASK R TO STAND AT BEGINNING OF STRING
When I say “Begin” you may start walking.
PUSH ‘START/STOP’ AND SAY:
‘Begin’
PUSH ‘START/STOP’ WHEN ONE OF R’S FEET IS COMPLETELY ACROSS THE OTHER END OF THE STRING
WALKREAS1
WALKREAS1
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
WALKOS1
WALKOS1
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
CSINTRO
(01) ABLE TO DO (SPECIFY SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
(01) WALKPROB
(996) WALKREAS2
(01)-(06), (-8), (-9) CSINTRO
(91) WALKOS2
CSINTRO
ASK RESPONDENT TO REPEAT WALK, FROM THE END OF THE STRING BACK TO THE BEGINNING OF THE STRING
When I say “Begin” you may start walking.
WALKTIM2
WALKTIM2
code one
PUSH ‘START/STOP’ AND SAY:
‘Begin’
PUSH ‘START/STOP’ WHEN ONE OF R’S FEET IS COMPLETELY ACROSS THE OTHER END OF THE STRING
WALKREAS2
WALKREAS2
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
WALKOS2
WALKOS2
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
Page 51 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
WALKPROB
CSINTRO
WALKPROB
CSINTRO
code all
no entry
Revised HFQ- Health Status and Functioning
RECORD YOUR OBSERVATIONS OF THE R'S MEASURE. CHECK ALL THAT APPLY.
(01) R WALKED UNSTEADILY
(02) R LIMPED, SHUFFLED OR DRAGGED A LEG
(03) R USED A CANE
(04) R USED WALKER
(05) R STATED IT’S PAINFUL
(06) NOTHING APPLIES
Now I am going to ask you to stand up from a chair without using your arms. First, let me demonstrate this
measure. After I demonstrate the measure, please tell me if you cannot do this movement or if you feel it would
(01) CONTINUE
be unsafe to try.
(02) R CANNOT OR WILL NOT PARTICIPATE
CSINTRO
(01) SNGLCS
(02) SNGLREAS
[IF R REFUSES TO ATTEMPT THE MEASURE, CODE (02) R CANNOT OR WILL NOT PARTICIATE]
SNGLCS
SNGLCS
code one
DEMONSTRATE CHAIR STAND WHILE PROVIDING INSTRUCTIONS
SIT IN CHAIR WITH YOUR FEET ON THE FLOOR. SIT SO THAT YOU CAN PLACE THE WIDTH OF YOUR HANDS
BETWEEN THE CHAIR AND YOUR KNEES.
FOLD YOUR ARMS ACROSS YOUR CHEST
STAND UP, KEEPING YOUR ARMS FOLDED ACROSS YOUR CHEST
(01) R STOOD WITHOUT USING ARMS
[996] TEST COULD NOT BE COMPLETED
(01) CSINTRO2
(03) SNGLREAS
(01)-(06), (-8), (-9) BOX HFEND
(91) SNGLCSOS
When I say ‘Begin’ you may stand up straight from the chair.
IF R CANNOT RISE WITHOUT USING ARMS, ASK R TO TRY TO STAND UP USING ARMS
SNGLREAS
SNGLREAS
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
SNGLCSOS
SNGLCSOS
verbatim text
OTHER (SPECIFY)
(01) [Continuous answer]
BOX HFEND
no entry
Now I'm going to ask you to stand up and sit down as quickly as you can five times, keeping your arms folded
across your chest. I'm going to demonstrate one for you.
(01) CONTINUE
RPTDCS
(01) TIME TO COMPLETE FIVE STANDS (SPECIFY
SECONDS): ______
[996] TEST COULD NOT BE COMPLETED
(01) BOX HFEND
(996) CSREAS
CSINTRO2
CSINTRO2
DEMONSTRATE 1 CHAIR STAND WHILE PROVIDING INSTRUCTIONS
SIT IN CHAIR WITH YOUR FEET ON THE FLOOR
FOLD YOUR ARMS ACROSS YOUR CHEST
STAND UP AND SIT DOWN ONCE
TELL R TO REPEAT THAT 4 MORE TIMES
When I say “Begin” you may stand up.
RPTDCS
RPTDCS
code one
PUSH ‘START/STOP’ AND SAY ‘Begin’
COUNT OUT LOUD AS RESPONDENT ARISES EACH TIME
PUSH ‘START/STOP’ WHEN R HAS COMPLETELY STOOD UP FROM THE CHAIR FOR THE 5TH TIME
STOP THE EXERCISE EARLY IF R CANNOT RISE WITHOUT USING ARMS, R IS TOO TIRED TO CONTINUE, OR R IS
UNABLE TO COMPLETE AFTER 1 MINUTE
Page 52 of 53
MCBS Nonsubstantive Change Request Fall 2020 Round 88
Revised HFQ- Health Status and Functioning
CSREAS
CSREAS
code one
CODE THE PRIMARY REASON WHY THE TEST COULD NOT BE COMPLETED
CSOS
CSOS
BOX HFEND
verbatim text
routing
OTHER (SPECIFY)
GO TO NAQ.
(01) EQUIPMENT PROBLEM
(02) NO SUITABLE SPACE TO CONDUCT THE MEASURE
(03) R UNABLE TO UNDERSTAND INSTRUCTIONS
(04) NOT ATTEMPTED, FI FELT IT WAS UNSAFE
(05) NOT ATTEMPTED, R FELT UNSAFE
(06) ATTEMPTED, UNABLE TO DO
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(06), (-8), (-9) BOX HFEND
(91) CSOS
(01) [Continuous answer]
BOX HFEND
Page 53 of 53
| File Type | application/pdf |
| File Title | Revised Health Status and Functioning (HFQ) section.xlsx |
| Author | Wishart-Marisa |
| File Modified | 2019-11-25 |
| File Created | 2019-11-25 |