CMS-P-0015A Chronic Pain

2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

CPQ- CHRONIC PAIN

Question Type

Question Text/Description

Code List

Routing

CHRONIC PAIN QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=INTTYPE=C001, C002, C004, C005, C006, C010
SPALIVE=1
SEASON=SUMMER
SPPROXY=SP
Other:
PLACEMENT
Administer after PVQ

SHOW CARD CP1
Now I would like to ask about your experiences with pain.
PAINOFTN

CP1

code one

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

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

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

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

SHOW CARD CP2
PAINAMNT

CP2

code one

PAINLIMT

CP3

code one

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

SHOW CARD CP1
Since (TODAY'S MONTH AND YEAR - 3 MONTHS), how often did your pain limit your life or work activities? Would you
say never, some days, most days, or every day?

SHOW CARD CP1
PAINFAM

CP4

code one

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

SHOW CARD CP3
PAINMANG

CP5

code one

MANGPHYS

CP6

list

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

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

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

CP3 - PAINLIMT

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

CP4 - PAINFAM

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

CP5 - PAINMANG

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

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

CP6 - MANGPHYS

CP6- MANGSPNE

MANGSPNE

CP6

list

Spinal manipulation or other forms of chiropractic care

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

CP6- MANGCBT

MANGCBT

CP6

list

Talk therapies such as cognitive-behavioral therapy (CBT)

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

CP6 - MANGPROG

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2020 MCBS Community Questionnaire

CPQ- CHRONIC PAIN

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

MANGPROG

CP6

list

A chronic pain self-management program or workshop

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

CP6 - MANGGROP

MANGGROP

CP6

list

Chronic pain peer support groups

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

CP6- MANGYOGA

MANGYOGA

CP6

list

Yoga, tai chi, or qi gong

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

CP6- MANGMASG

MANGMASG

CP6

list

Massage

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

CP6- MANGMEDT

MANGMEDT

CP6

list

Meditation, guided imagery, or other relaxation techniques

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

CP7-PAINBACK

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

CP8- PAINARMS

SHOW CARD CP3
Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by...
PAINBACK

CP7

code one
Back pain?
Would you say not at all, a little, a lot, or somewhere in between?

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

CP8

code one
Pain in your hands, arms, or shoulders?

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

CP9 - PAINLEGS

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

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

CP9

code one
Pain in your hips, knees, or feet?

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

CP10 - PAINHEAD

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

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

CP10

code one
Headache, migraine, or facial pain?

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

CP11 - PAINABDM

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

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2020 MCBS Community Questionnaire

Variable Name

MR Screen Name

CPQ- CHRONIC PAIN

Question Type

Question Text/Description

Code List

SHOW CARD CP3

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

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

CP11

code one
Abdominal, pelvic, or genital pain?

Routing

CP12 - PAINTOTH

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

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

CP12

code one
Toothache or jaw pain?

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

BOX CPEND

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

BOX CPEND

routing

Go to PXQ.

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