CMS-P-0015A Medical Provider Utilzation

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

Code List

Routing

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

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

MEDICAL PROVIDER UTILIZATION QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C004, C005, C006, C007, C010
SPALIVE=ALL
SEASON=ALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
Administer after HHQ.

MPPRMDOC

MP1

yes/no

(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] any medical doctors?
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
SEE MPQ JOB AID 1 FOR TYPES OF MEDICAL DOCTORS, IF NECESSARY.
[DO NOT INCLUDE MEDICAL DOCTORS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT
OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

(01) [Continuous answer.]

PROVIDER_MP

MP2

roster

[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
SELECT OR ADD ONLY ONE PROVIDER.
2. [PROVIDER 2]
…
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING N. [PROVIDER N]
AN EVENT WITH THAT PROVIDER
N+1. ADD ANOTHER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

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

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

PROVNAME

MP2

verbatim

YOU MUST ENTER A PROVIDER NAME IN THE ‘NAME’ FIELD. IF THE PROVIDER IS AN INDIVIDUAL BUT
YOU DO NOT KNOW THE PROVIDER’S NAME, OR IF THE PROVIDER IS AN ORGANIZATION, ENTER THE
GROUP OR PRACTICE NAME IN THE ‘NAME’ FIELD AND LEAVE THE ‘GROUP’ FIELD BLANK.

MP2-GROUPNAM

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

GROUPNAM

MP2

GROUP:

WHICH PROVIDER IS MISSPELLED?

CHNGSPL

CHNGSPL

roster

THIS SCREEN IS ONLY FOR CORRECTING MISSPELLINGS. TO ADD A NEW PROVIDER, BACK UP AND
SELECT "ADD ANOTHER."

BOX MP1B
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
1. [PROVIDER 1]
2. [PROVIDER 2]
…
N. [PROVIDER N]

CRCTSPL-CRCTSPL

ONLY SELECT A PROVIDER IF YOU ARE CURRENTLY ENTERING AN EVENT WITH THAT PROVIDER. IF
YOU ARE NOT CURRENTLY ENTERING AN EVENT WITH A MISSPELLED PROVIDER, BACK UP TO SELECT
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
OR ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.

CRCTSPL

CRCTSPL

verbatim

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

BOX MP1B

routing

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

(01) [Continuous Answer]

BOX MP1B

Page 1 of 10

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

What kind of (health practitioner/mental health professional/therapist/medical person) is (PROVIDER NAME)?
[SELECT THE RESPONSE CATEGORY FOR A GIVEN SPECIALTY ONLY IF THE RESPONDENT
SPECIFICALLY NAMES THE LISTED SPECIALTY OR MENTIONS THE WORDS OR INITIALS IN
PARENTHESES FOLLOWING THAT PROVIDER SPECIALTY. IF THE RESPONDENT NAMES A MEDICAL
SPECIALTY NOT LISTED BELOW, BUT LISTED ON MPQ JOB AID 1, SUCH AS ‘CARDIOLOGY,’ SELECT
'MEDICAL DOCTOR.']

PROVSPEC

MP2A

code 1

PROVSPOS

MP2A

verbatim text

OTHER MEDICAL PROVIDER (SPECIFY)

BOX MP1

routing

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND) AND (IF THIS PROVIDER IS ASSOCIATED WITH V.A. IS UNKNOWN), GO TO MP3 VAPLACE.
ELSE GO TO BOX MP2.

MP3

yes/no

Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?

BOX MP2

routing

IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO MP4 - HMOASSOC.
ELSE IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (THIS
PROVIDER IS NOT ASSOCIATED WITH A MANAGED CARE PLAN), GO TO MP5 - HMOREFER.
ELSE GO TO MP6 - EVENT.

HMOASSOC

MP4

yes/no

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

HMOREFER

MP5

yes/no

VAPLACE

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

Code List

Routing

(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR
(03) AUDIOLOGIST
(04) CHIROPRACTOR
(05) CLINICAL SOCIAL WORKER
(06) DIETITIAN-NUTRITIONIST
(07) HEARING THERAPIST
(08) HOME HEALTH/HEALTH AIDE
(09) HOMEMAKER
(10) HOSPICE WORKER
(11) I.V. THERAPIST
(12) NURSE (RN)
(13) NURSE PRACTITIONER
(14) NURSE'S AIDE
(15) OCCUPATIONAL THERAPIST (OT)
(16) OPTOMETRIST (OD)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(42) PHARMACIST
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(21) PODIATRIST (FOOT DOCTOR)
(22) PSYCHOLOGIST
(23) RESPIRATORY THERAPIST
(24) SOCIAL/CASE WORKER
(25) SPEECH THERAPIST
(26) THERAPIST (MENTAL HEALTH)
(27) X-RAY TECHNICIAN
(28) LICENSED PRACTICAL NURSE (LPN)
(29) ACUPUNCTURIST
(30) HOMEOPATH
(31) MASSAGE THERAPIST
(32) NATUROPATH
(33) LICENSED PROFESSIONAL COUNSELOR [LPC]
(34)LAB TECHNICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) Don't Know
(-9) Refused

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

(01) [Continuous answer.]

BOX MP1

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

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

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

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

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

MP6 - EVENT

Page 2 of 10

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

Code List

Routing

(01) [Continuous answer.]

MP6-MPADD

(01) ADD ANOTHER
(02) ALL DONE

(01) MP6 -EVENT
(02) BOX MP2AA

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

(01) BOX MP2B
(02)TELEHLTH-TELEHLTH
(-8) TELEHLTH-TELEHLTH
(-9) TELEHLTH-TELEHLTH.

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

BOX MP2C

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

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

When did [you/(SP)] see (PROVIDER NAME)? Please tell me all the dates [since (REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
ENTER ALL DATES.
EVENT

MP6

roster

[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
IF R HAD 5 OR MORE VISITS TO THIS PROVIDER DURING THIS REFERENCE PERIOD, SELECT "REPEAT
VISITS" AND LEAVE THE DAY FIELD BLANK. ENTER EACH MONTH SEPARATELY.
HAVE ALL DATES BEEN ENTERED?

MPADD

MP6

choose one
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]

MPSDVIS

BOX MP2AA

routing

FOR FIRST/NEXT EVENT ENTERED AT MP6, IF (PROVIDER SPECIALTY IS A MEDICAL DOCTOR) AND
((EVENT DATE OVERLAPS AN EXISTING IP EVENT) OR (EVENT DATE MATCHES AN EXISTING ER OR OP
EVENT), GO TO MP6B - MPSDVIS.
ELSE GO TO TELEHLTH-TELEHLTH.

MP6B

yes/no

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

BOX MP2B

routing

UPDATE EVENT TYPE TO SEPARATELY BILLING DOCTOR AND GO TO BOX MP6AA.

TELEHLTH

yes/no

BOX MP2C

routing

[Was this visit/Were any of these visits] to (PROVIDER NAME) a telephone or video visit?
TELEHLTH

IF NEEDED: Telephone or video visits are also referred to as “telehealth visits”, “virtual check-ins”, or “e-visits”.
These types of visits allow you to have a medical appointment without physically visiting your doctor’s office.

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

IF THIS VISIT OR THESE VISITS WERE TELEHEALTH VISITS, SELECT NO WITHOUT READING THE TEXT
BELOW.
ANYOPERS

MP7

yes/no

Were any operations or other surgical procedures performed on [you/(SP)] during ([the visit on [EVENT DATE]/
[any of these visits in (EVENT MONTH/YEAR)]/[the 1 visit in (EVENT MONTH/YEAR)])
[Operations include surgery and other surgical procedures like setting bones, stitching or removing growths, or any
cutting of the skin.]

SPECCOND

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

MP10

yes/no

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

BOX MP2D

routing

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

PRESMDCN

MP12

yes/no

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

PRESFILL

MP13

yes/no

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

BOX MP3A

routing

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

Were any of the prescriptions filled?

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

BOX MP2D

(01) MP13 - PRESFILL
(02) BOX MP6AA
(-8) BOX MP6AA
(-9) BOX MP6AA

(01) BOX MP3A
(02) BOX MP6AA
(-8) BOX MP6AA
(-9) BOX MP6AA

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2021 MCBS Community Questionnaire

Variable Name

MPPMMEDS

MR Screen Name

MP13A

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

no entry

Question Text/Description

Code List

It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)]
(MEDICARE PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same
(01) CONTINUE
information on them.]
(-7) Empty

Routing

BOX PM2

[IF RESPONDENT HAS BOTTLE, ASK:] I’ll need that same information for all of the medicines [you/(SP)]
obtained since (REFERENCE DATE/UTILDATE), if you’d like to get those bottles, too.

BOX PM2

MEDICINE_PM1

routing

IF THERE IS AT LEAST ONE MEDICINE FROM A PRIOR ROUND ON THE EVENT TABLE FOR THIS CASE,
GO TO MEDICINE_PM1-MEDICINE_PM1.
ELSE GO TO PM2B-PMBOTTLE.

MEDICINE_PM1

code one

What is the name of the medicine?

BOX PM3

routing

IF THIS MEDICINE HAS AN EXACT MATCH TO THE FDB LIST ( PMEDID^=.), THEN GO TO PM2ASAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.

[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
BOX PM3
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.

CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
The strength was [MEDICINE STRENGTH].
SAMEFSAM

SAMEFSAM

yes/no
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).

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

BOX PM4

(01) YES
(02) NO
(03) NO BUT R CAN ANSWER QUESTIONS
(-8) DON'T KNOW
(-9) REFUSED

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

Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.

PMBOTTLE

BOX PM4

routing

IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.

PMBOTTLE

code one

CODE “YES” WITHOUT ASKING IF BOTTLE, CONTAINER, BAG, STATEMENT, OR RECEIPT IS PRESENT.
Do you have the medicine bottle, container or bag, or Prescription Drug Plan Statement available?
IF R DOES NOT HAVE DOCUMENTATION, PROBE TO DETERMINE IF R CAN ANSWER QUESTIONS
ABOUT THE FORM, STRENGTH, AND QUANTITY OF THE MEDICINE.

TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
PMEDNAME

MED

lookup

[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]

[PRESCRIBED MEDICINE LOOKUP TOOL]

PMBRNAME
PMGNNAME
PMFORMFD

MED
MED
MED

lookup
lookup
lookup

[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]

Page 4 of 10

2021 MCBS Community Questionnaire

Variable Name

PMFORMMC

MR Screen Name

MED

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

code one

Question Text/Description

Code List

Routing

Medicine Form [MCBS FORM]

(01) PILLS (TABLETS, CAPSULES)
(02) LIQUID (TO BE TAKEN ORALLY)
(03) DROPS (EYE/EAR/NOSE)
(04) OINTMENT, CREAM, LOTION (TOPICAL OR
INTERNAL)
(05) SUPPOSITORIES
(06) AEROSOL/SPRAY, INHALANT, SOLUTIONS,
DISKUS
(07) SHAMPOO, SOAP
(08) INJECTION
(09) IV INJECTION
(10 PATCHES
(11) GEL OR JELLY (TOPICAL OR INTERNAL)
(12) POWDER, GRANULES
(91) OTHER
(-8) Don't Know
(-9) Refused

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

(01) CONTINUOUS ANSWER

PMFORMOS

MED

verbatim

[MEDICINE FORM OTHER SPECIFY]

PMFORMFN

MED

verbatim

[FINAL CONCATENATED MEDICINE FORM]

PMSTRNFD

MED

verbatim

Medicine Strength

STRNNUMBB

MED

numeric

Medicine strength number

STRNUNIT

MED

code one

PMSTRNOS

MED

verbatim

[MEDICINE STRENGTH UNIT OTHER SPECIFY]

PMSTRUNI

MED

ookup

[FINAL CONCATENATED MEDICINE STRENGTH]

PMEDID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]

FAMILYID

MED

numeric

[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]

PMKNWNM

PMKNWNM

code one

DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?

Medicine strength unit

What condition is this medicine prescribed for or what is its primary use?
PMCOND

PMCOND

code one
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.

(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
(01) CONTINUOUS ANSWER
(01) MICROGRAMS (mcg, mc)
(02) MILLIGRAMS (mg)
(03) GRAINS (gr)
(04) MILLIEQUIVALENTS (meq)
(05) GRAMS (g, gm)
(06) PERCENT (%)
(07) INTERNATIONAL UNITS (IU)
(08) UNITS (U)
(91) OTHER
(-8) Don't Know
(-9) Refused

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

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

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

(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(20) OTHER
(-8) DON'T KNOW
(-9) REFUSED

(01)-(19) GETNUM-GETNUM
(20) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM

Page 5 of 10

2021 MCBS Community Questionnaire

Variable Name
PMCONDOS

MR Screen Name
PMCOND

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type
verbatim

Question Text/Description

Code List

OTHER (SPECIFY)

(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED

How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
GETNUM

TABNUM

GETNUM

numeric

[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND,
CHECK “ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF
REFILLS.]

Routing

(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
(-9) Refused

BOX PM5

BOX PM5

routing

IF GETNUM=996/EVENT ENTERED IN ERROR OR PMKNWNM=02/NO OR SAMEFSAM=1/YES, GO TO
PMMORE-PMMORE;
IF SAMEFSAM=1/YES AND PMFORMFN=pills (tablets, capsules), GO TO PM12-TABSADAY;
ELSE IF MEDICINE FORM IS PILLS, TABLETS OR CAPSULES [PMFORMMC=1 OR PMFORMFD CONTAINS
("PILL", "TAB", "CAP") GO TO TABNUM-TABNUM;
ELSE GO TO PM16-AMTUNIT.

TABNUM

numeric

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

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

BOX PM6

HOW MUCH MEDICINE WAS IN THE CONTAINER WHEN IT WAS OBTAINED?
[PLEASE ENTER THE AMOUNT IN THE CONTAINER, NOT THE STRENGTH OF THE MEDICINE.]

(01) OUNCES (oz)
(02) GRAMS (g, gm)
(03) MILLILITERS (ml, cc)
(04) MILLIEQUIVALENTS (meq)
(05) MILLIGRAMS (mg)
(06) MICROGRAMS (mcg)
(07) PUFFS, DOSES, BLISTERS
(91) OTHER
(-8) DON'T KNOW

(01) PM16 - AMTNUM
(02) PM16 - AMTNUM
(03) PM16 - AMTNUM
(04) PM16 - AMTNUM
(05) PM16 - AMTNUM
(06) PM16 - AMTNUM
(07) PM16 - AMTNUM
(91) PM16 - AMTUNOS
(-8) BOX PM6

(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER

PM16 - AMTNUM
BOX PM6

AMTUNIT

PM16

quantity unit

AMTUNOS
AMTNUM

PM16
PM16

text
numeric

BOX PM6

routing

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

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

TABSADAY

PM12

numeric

TABSADAY95

PM12

code one

IF LESS THAN ONE UNIT IS TO BE TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX:
HALF A PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TO BE TAKEN “AS NEEDED,” ENTER THE MAXIMUM AMOUNT THAT IS TO BE TAKEN IN A (01) CONTINUOUS ANSWER
DAY AND SELECT "TAKE AS NEEDED".
FOR MEDICINES TO BE TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".
IF THE AMOUNT TO BE TAKEN PER DAY IS NOT CLEAR OR NOT INDICATED, SELECT "DON'T KNOW".

(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) Empty

PM12 - TABSADAY95

PM13-TABTAKE

How many pills, tablets, or capsules (do/did/does) [you/(SP)] usually take in a day?
[READ IF NECESSARY: This question is asking about how often you actually take the medicine, not how often the
medicine is prescribed to be taken.]

TABTAKE

PM13

numeric

TABTAKE96

PM13

code one

BOX PM7

routing

IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A
PILL SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER
DOSING INSTRUCTIONS".

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

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

PM13 - TABTAKE96

BOX PM7

IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR
ANY PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.

Page 6 of 10

2021 MCBS Community Questionnaire

Variable Name

PMSATVA

PMSATHMO

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

Code List

Routing

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

BOX PM8

PMSATVA

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?

BOX PM8

routing

IF SP COVERED BY A MEDICARE MANAGED CARE PLAN OR A PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO PMSATHMO - PMSATHMO.
ELSE GO TO PMMORE-PMMORE.

PMSATHMO

yes/no

Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?

(01) YES
(02) NO
(-8) DON'T KNOW
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)] (-9) REFUSED
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]

([NO MEDICINES HAVE BEEN REPORTED FOR (SP) FOR THE CURRENT REFERENCE PERIOD/THE
NAMES OF ALL MEDICINES REPORTED FOR THE CURRENT REFERENCE PERIOD ARE DISPLAYED
BELOW.])
PMMORE

PM17

(01) ADD ANOTHER
(02) ALL DONE

(01) BOX PM2
(02) BOX MP6AA

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

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

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

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

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

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

yes/no
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]

MDOCMORE

BOX MP6AA

routing

MP17

yes/no

IF ANOTHER MP EVENT WAS ADDED WITH THIS MEDICAL PROVIDER, GO TO BOX MP2AA.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP1 PROBE, GO TO MP17 MDOCMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP18 PROBE, GO TO MP25 PRACMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP26 PROBE, GO TO MP33 MENTMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP34 PROBE, GO TO MP41 THERMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP42 PROBE, GO TO MP49 PERSMORE.
ELSE IF MEDICAL PROVIDER VISIT WAS REPORTED FOLLOWING MP50 PROBE, GO TO MP56 MPPRMORE.

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

BOX MP6A

MPHPRAC

MP18

routing

yes/no

PMMORE-PMMORE

IF WINTER ROUND AND (SP IS ALIVE AND NOT INSTITUTIONALIZED) AND (SP REPORTED A MEDICAL
PROVIDER VISIT AT MP6 AND MP6B - MPSDVIS ^= 1/Yes AND PROVIDER'S SPECIALTY IS A MEDICAL
DOCTOR), GO TO AC20 - DRSPCLTY,
ELSE GO TO MP18 - MPHPRAC.

SHOW CARD MP1
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] [seen/see] a health practitioner like any of the ones listed on this card? [Health practitioners include
acupuncturist, chiropractor, podiatrist (foot doctor), homeopath, naturopath, or any other kind of health provider
who is not a medical doctor.]
INCLUDE ANY VISITS FOR TESTS/X-RAYS.
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT
OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

PRACMORE

MP25

yes/no

Page 7 of 10

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

Code List

Routing

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

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

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

SHOW CARD MP2

MPPRMENT

MP26

yes/no

(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(SP)/did (SP)] (seen/see) a mental health professional like any of the ones listed on this card? [Mental health
professional includes psychiatrist, psychologist, clinical social worker, and licensed professional counselor.]
[DO NOT INCLUDE PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT OR
CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

MENTMORE

AFRDMT

MP33

yes/no

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

BOX MP7

routing

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

MP33B

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there any time when
[you/(SP)] needed mental health care or counseling, but [you/he/she] didn’t get mental health care because
[you/he/she] couldn't afford it?

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

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

MP34-MPPRTHER

MPPRTHER

MP34

yes/no

SHOW CARD MP3
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(01) YES
(SP)/did (SP)] (seen/see) a therapist like any of the ones listed on this card? [Therapist includes physical therapist (02) NO
speech therapist, intravenous (IV) therapist, massage therapist, occupational therapist, and respiratory therapist.] (-8) Don't Know
(-9) Refused
[DO NOT INCLUDE MEDICAL PROVIDERS SEEN IN THE EMERGENCY ROOM, OUTPATIENT DEPARTMENT
OR CLINIC, AT THE RESPONDENT’S HOME, OR DURING AN INPATIENT STAY.]

THERMORE

MP41

yes/no

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

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

yes/no

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

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

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

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

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

MPPRPERS

PERSMORE

MP42

MP49

yes/no

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

Page 8 of 10

2021 MCBS Community Questionnaire

Variable Name

MPPRPLAC

MR Screen Name

MP50

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

yes/no

Question Text/Description

Code List

SHOW CARD MP5
(Besides what you have already mentioned), [(Since/since (REFERENCE DATE/UNTILDATE)/(Between/between)
(REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD), [have you/has
(01) YES
(SP)/did (SP)] (visited/visit) any other types of medical places like the ones listed on this card? [Other types of
(02) NO
medical places include health clinic, neighborhood health center, rural health clinic, infirmary, mental health clinic,
(-8) Don't Know
urgent care center, or any other place.]
(-9) Refused

Routing

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

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

MPPRMORE

[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other visits to this place or any other type of
medical place?

(01) YES
(02) NO
(-8) Don't Know
[DO NOT INCLUDE VISITS TO THE EMERGENCY ROOM, OUTPATIENT DEPARTMENTS, INPATIENT STAYS, (-9) Refused
OR SENIOR DAY CARE.]

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

MP56

yes/no

BOX MP8

routing

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

MCDRNSEE

SC11

yes/no

Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], did [you/(SP)] have any health
problem or condition about which you think [you/he/she] should have seen a doctor or other health professional,
but did not?
[INCLUDE ALL TYPES OF HEALTH PROBLEMS RANGING FROM MINOR TO SERIOUS ISSUES.]

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

(01) SC12AA - TEMPCOND1
(02) BOX MP22
(-8) BOX MP22
(-9) BOX MP22

TEMPCOND1

SC12AA

text

(01) [Continuous answer.]

SC12AA - TEMPCOND2

TEMPCOND2

SC12AA

text

SC12AA

text

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

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

TEMPCOND3

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

SC12A - MCDRATMP

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

MCDRATMP

SC12A

yes/no

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

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

SC13A - SCRCODES

[PROBE: By "attempt" I mean, did [you/(SP)] contact a doctor’s office or other medical place in order to set an
appointment or talk to someone about the condition(s)?]

SCRCODES

SC13A

code all

SHOW CARD MP6
(01) DIDN'T THINK THE PROBLEM WAS SERIOUS
This card lists some reasons people have given for not seeing a doctor or other health professional about a health (02) THOUGHT IT WOULD COST TOO MUCH
problem or condition.
(03) TROUBLE FINDING/GETTING TO DOCTOR
(04) TIME/SCHEDULE OR PERSONAL CONFLICTS
Which of these reasons explains why [you/(SP)] did not see a doctor or other health professional about the [READ (05) THOUGHT DOCTOR COULDN'T DO MUCH
CONDITION(S) BELOW]?
ABOUT PROBLEM
(06) WAS AFRAID OF FINDING OUT WHAT WAS
(CONDITION 1 FROM SC12AA)
WRONG
(CONDITION 2 FROM SC12AA)
(07) DOCTOR WOULD NOT ACCEPT MY INSURANCE
(CONDITION 3 FROM SC12AA)
(91) (OTHER/SC13A - SCROTOS OTHER SPECIFY
TEXT)
[PROBE: Any other reason?]
(-8) Don't Know
CHECK ALL THAT APPLY.
(-9) Refused

SCROTOS

SC13A

verbatim text

OTHER (SPECIFY)

routing

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

BOX SC1B

(01) [Continuous answer.]

(01) BOX SC1B
(02) BOX SC1B
(03) BOX SC1B
(04) BOX SC1B
(05) BOX SC1B
(06) BOX SC1B
(07) BOX SC1B
(91) SC13A - SCROTOS
(-8) BOX MP22
(-9) BOX MP22

BOX SC1B

Page 9 of 10

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name

MPQ-MEDICAL PROVIDER UTILIZATIO

Question Type

Question Text/Description

Which of these was the main reason [you/(SP)] did not see a doctor or other health professional about (this
condition/these conditions) during [CURRENT YEAR -1]?
[READ REASONS BELOW IF NECESSARY.]
SCRMAIN

SC14A

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

BOX MP22

routing

Code List

Routing

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

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

Page 10 of 10