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pdf2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
(01) IN-PERSON
(02) PHONE
DUINT- DUINTRO
DENTAL, VISION, & HEARING CARE 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 HIQ.
PHONDVH
PHONDVH
code one
ARE THE UTILIZATION AND COST SECTIONS BEING CONDUCTED IN-PERSON OR OVER THE PHONE?
The next questions are about any medical care [you/(SP)] may have had between (REFERENCE DATE/UTILDATE)
and (today/DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD).
DUINT
DUINTRO
no entry
(Now would be a good time to get out the planner that [you/(SP)] may have used to record health care visits or other
medical expenses. We will also refer to any statements [you/(SP)] may have received since the last interview.)
DU1 - DUPROBE
First, we’ll talk about dental care.
DUPROBE
DU1
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a dentist or any other person for dental care? [Dental
providers include dentists, dental surgeons, endodontists, periodontists, and dental hygienists.]
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) BOX DU5
(-9) BOX DU5
(01) [Continuous answer.]
PROVIDER_DU
DU2
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
(01-N) BOX DU1
(N+1) DU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX DU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO DU2BPROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL-CHNGSPL.
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
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.
PROVNAME
DU2B
verbatim text
DU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
GRPNAME
DU2B
verbatim text
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."
PROVSPEC
[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 OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
Page 1 of 25
2023 MCBS Community Questionnaire
Variable Name
CRCTSPL
PROVSPEC
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
Code List
Routing
CRCTSPL
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]
(01) [Continuous Answer]
BOX DU1
What kind of dental provider is [PROVNAME]?
(01) GENERAL DENTIST
(35) DENTAL HYGIENIST
(36) DENTAL TECHNICIAN
(37) DENTAL/ORAL SURGEON
(38) ORTHODONTIST
(39) ENDODONTIST
(40) PERIODONTIST
(41) PROSTHODONTIST
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU2
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(91) DU2C1 - PROVSPEC
(-8) BOX DU2
(-9) BOX DU2
(01) DO NOT DISPLAY
(02) BOX DU2
(03) BOX DU2
(04) BOX DU2
(05) BOX DU2
(06) BOX DU2
(07) BOX DU2
(08) BOX DU2
(09) BOX DU2
(10) BOX DU2
(11) BOX DU2
(12) BOX DU2
(13) BOX DU2
(14) BOX DU2
(15) BOX DU2
(16) BOX DU2
(17) BOX DU2
(18) BOX DU2
(19) BOX DU2
(20) BOX DU2
(21) BOX DU2
(22) BOX DU2
(23) BOX DU2
(24) BOX DU2
(25) BOX DU2
(26) BOX DU2
(27) BOX DU2
(28) BOX DU2
(29) BOX DU2
(30) BOX DU2
(31) BOX DU2
(32) BOX DU2
(33) BOX DU2
(34) BOX DU2
(91) DU2D - PROVSPOS
(-8) BOX DU2
(-9) BOX DU2
DU2C
verbatim
code one
PROVSPEC
DU2C1
code one
What kind of dental provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER (DO NOT DISPLAY)
(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
(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
PROVSPOS
DU2D
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
BOX DU2
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 DU3 VAPLACE.
ELSE GO TO BOX DU2.
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX DU2
BOX DU1
VAPLACE
DU3
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
Page 2 of 25
2023 MCBS Community Questionnaire
Variable Name
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
BOX DU2
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 DU4 - 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 DU5 - HMOREFER.
ELSE GO TO DU6 - EVENT_DU.
routing
HMOASSOC
DU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFER
DU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
EVENT_DU
DU6
roster
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.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
DU6B
chose one
DU7
code all
PRESMDCN
DU7A
DU9
verbatim text
yes/no
(01) DU6 - EVENT_DU
(02) DU5 - HMOREFER
(-8) DU5 - HMOREFER
(-9) DU5 - HMOREFER
DU6 - EVENT_DU
(01) continuous answer
(-8) Don't Know
(-9) Refused
(01) ADD ANOTHER
(02) ALL DONE
(01) DU6 -EVENT_DU
(02) DU7-DVPROCDR
(01) GENERAL EXAM, CHECKUP OR CONSULTATION
(02) CLEANING, PROPHYLAXIS, OR POLISHING
(03) X-RAYS, RADIOGRAPHS, OR BITEWINGS
(04) FLUORIDE TREATMENT
(05) SEALANT (PLASTIC COATINGS ON BACK TEETH)
(06) FILLINGS
(07) INLAYS
(08) CROWNS OR CAPS
(09) ROOT CANAL
(10) PERIODONTAL SCALING, ROOT PLANING, OR
GUM SURGERY
(11) PERIODONTAL RECALL VISIT (PERIODIC OR
REGULAR)
(12) EXTRACTION, TOOTH PULLED
(13) IMPLANTS
(14) ABSCESS OR INFECTION TREATMENT
(15) OTHER ORAL SURGERY
(16) FIXED BRIDGES
(17) DENTURES OR REMOVABLE PARTIAL
DENTURES
(18) RELINING OR REPAIR OF BRIDGES OR
DENTURES
(19) ORTHODONTIA, BRACES, OR RETAINERS
(20) BOND, WHITEN, OR BLEACH
(21) TREATMENT FOR TMD OR TMJ
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) DU9-PRESMDCN
(02) DU9-PRESMDCN
(03) DU9-PRESMDCN
(04) DU9-PRESMDCN
(05) DU9-PRESMDCN
(06) DU9-PRESMDCN
(07) DU9-PRESMDCN
(08) DU9-PRESMDCN
(09) DU9-PRESMDCN
(10) DU9-PRESMDCN
(11) DU9-PRESMDCN
(12) DU9-PRESMDCN
(13) DU9-PRESMDCN
(14) DU9-PRESMDCN
(15) DU9-PRESMDCN
(16) DU9-PRESMDCN
(17) DU9-PRESMDCN
(18) DU9-PRESMDCN
(19) DU9-PRESMDCN
(20) DU9-PRESMDCN
(21) DU9-PRESMDCN
(91) DU7A-EVOSTEXT
(-8) DU9-PRESMDCN
(-9) DU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
DU9 - PRESMDCN
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU10 - PRESFILL
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
DU6B-DUADD
SHOW CARD DVH1
DVPROCDR
Routing
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
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.
DUADD
Code List
Page 3 of 25
2023 MCBS Community Questionnaire
Variable Name
PRESFILL
DUPMMEDS
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
Code List
Routing
DU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX DU3B
(02) BOX DU4
(-8) BOX DU4
(-9) BOX DU4
BOX DU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO DU10A - DUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
DU10A
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[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 PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(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.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
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.
Page 4 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
TO USE THE MEDICINE LOOKUP, START TYPING THE MEDICINE NAME IN THE PRESCRIBED MEDICINE
LOOKUP BOX. CHECK STATEMENT OR MEDICINE BOTTLE FOR SPELLING.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
PMEDID
MED
numeric
FAMILYID
MED
numeric
PMKNWNM
PMKNWNM
code one
Medicine Form [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
Medicine strength unit
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(-8) MED-PMSTRNFD
(-9) MED-PMSTRNFD
(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-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES ADDED THROUGH THE
LOOKUP. IT IS HIDDEN ON SCREEN.]
[THIS VARIABLE STORES THE UNIQUE IDENTIFIER FOR PRESCRIBED MEDICINES BY NAME ONLY,
EXCLUDING STRENGTH AND FORM, THROUGH THE LOOKUP. IT IS HIDDEN ON SCREEN.]
DOES THE RESPONDENT KNOW THE NAME OF THE MEDICINE?
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
Page 5 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
GETNUM
TABNUM
GETNUM
numeric
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
Code List
Routing
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(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)]]?
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]
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
(-9) REFUSED
(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) PM16 - AMTNUM
(-9) PM16 - AMTNUM
(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.
Page 6 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
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
TABTAKE96
PMSATVA
PMSATHMO
PM13
numeric
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
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]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)]
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([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
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?]
PM13 - TABTAKE96
BOX PM7
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX DU4
Page 7 of 25
2023 MCBS Community Questionnaire
Variable Name
DUMORE
DVNEED
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
BOX DU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO DU7-DVPROCDR.
ELSE GO TO DU14-DUMORE.
DU14
yes/no
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other dental care visits to this or any other provider? (-8) Don't Know
(-9) Refused
BOX DU5
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO DU15-DVNEED. ELSE GO TO BOX DU6.
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed dental care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) DU16 - DVNDRS
(02) BOX DU6
(-8) BOX DU6
(-9) BOX DU6
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DENTAL OFFICE IS TOO FAR AWAY
(05) DENTAL OFFICE IS NOT OPEN AT CONVENIENT
TIMES
(06) ANOTHER DENTIST RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DENTISTS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED DENTAL PROBLEMS TO GO
AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX DU6
(02) BOX DU6
(03) BOX DU6
(04) BOX DU6
(05) BOX DU6
(06) BOX DU6
(07) BOX DU6
(08) BOX DU6
(09) BOX DU6
(10) BOX DU6
(91) DU16A - DVNDRSOS
(-8) BOX DU6
(-9) BOX DU6
(01) continuous answer
BOX DU6
(01) YES
(02) NO
(03) INDICATED YES BY DATAPREP
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
DU15
DVNDRS
DU16
code all
What were the reasons that {you/SP} could not get the dental care {you/she/he} needed?
DVNDRSOS
DU16A
BOX DU6
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO VU1-VUPROBE.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to an eye doctor or any other person for eye care? [Eye
care providers include ophthalmologists, optometrists, and opticians.]
VUPROBE
VU1
Code List
Routing
(01) DU2 - PROVIDER_DU
(02) BOX DU5
(-8) BOX DU5
(-9) BOX DU5
(01) [Continuous answer.]
PROVIDER_VU
VU2
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
(01-N) BOX VU1
(N+1) VU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX VU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO VU2PROVNAME.
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.CHNGSPL..
Page 8 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
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.
VPRVNAME
VU2B
verbatim text
VU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
VGRPNAME
VU2B
verbatim text
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."
PROVSPEC
[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 OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
CRCTSPL
PROVSPEC
PROVSPEC
CRCTSPL
VU2C
VU2C1
verbatim
code one
code one
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]
(01) [Continuous Answer]
BOX VU1
What kind of eye care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OPHTHALMOLOGIST
(16) OPTOMETRIST (OD)
(43) OPTICIAN
(91) OTHER MEDICAL PROVIDER SPECIALTY
(-8) DON'T KNOW
(-9) REFUSED
(02) BOX VU1
(16) BOX VU1
(43) BOX VU1
(91) VU2C1 - PROVSPEC
(-8) BOX VU1
(-9) BOX VU1
What kind of eye care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(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) (DO NOT DISPLAY)
(17) OSTEOPATH (DO)
(18) PARAMEDIC
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(01) BOX VU1
(02) DO NOT DISPLAY
(03) BOX VU1
(04) BOX VU1
(05) BOX VU1
(06) BOX VU1
(07) BOX VU1
(08) BOX VU1
(09) BOX VU1
(10) BOX VU1
(11) BOX VU1
(12) BOX VU1
(13) BOX VU1
(14) BOX VU1
(15) BOX VU1
(16) DO NOT DISPLAY
(17) BOX VU1
(18) BOX VU1
(19) BOX VU1
(20) BOX VU1
Page 9 of 25
2023 MCBS Community Questionnaire
Variable Name
PROVSPOS
VAPLACE
MR Screen Name Question Type
VU2D
verbatim text
BOX VU1
routing
VU3
BOX VU2
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO VU4 - 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 VU5 - HMOREFER.
ELSE GO TO VU6 - EVENT_VU.
VU4
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
HMOREFR
VU5
yes/no
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
VU6
roster
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.
[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.
VUADD
VU6B
chose one
Routing
(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
(21) BOX VU1
(22) BOX VU1
(23) BOX VU1
(24) BOX VU1
(25) BOX VU1
(26) BOX VU1
(27) BOX VU1
(28) BOX VU1
(29) BOX VU1
(30) BOX VU1
(31) BOX VU1
(32) BOX VU1
(33) BOX VU1
(34) BOX VU1
(91) VU2D - PROVSPOS
(-8) BOX VU1
(-9) BOX VU1
OTHER MEDICAL PROVIDER (SPECIFY)
(01) [Continuous answer.]
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 VU3 VAPLACE.
ELSE GO TO BOX VU2.
HMOASSC
EVENT_VU
Code List
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
(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 VU1
BOX VU2
(01) VU6 - EVENT_VU
(02) VU5 - HMOREFER
(-8) VU5 - HMOREFER
(-9) VU5 - HMOREFER
VU6 - EVENT_VU
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
VU6B-VUADD
(01) ADD ANOTHER
(02) ALL DONE
(01) VU6 -EVENT_VU
(02) VU7-VUPROCDR
Page 10 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
(01) EYE OR VISION EXAM
(02) CONTACT LENS FITTING
(03) CONTACT LENS PURCHASE
(04) EYE GLASS FRAME FITTING OR ADJUSTMENT
(05) EYE GLASS PURCHASE
(06) REFRACTIVE SURGERY (CORRECTIVE VISION
SURGERY)
(07) CATARACT SURGERY
(08) GLAUCOMA SURGERY
(09) CORNEAL SURGERY
(10) VITREO-RETINAL SURGERY
(11) OCULOPLASTIC SURGERY
(12) EYE MUSCLE SURGERY
(13) EYE REMOVAL
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) VU9-PRESMDCN
(02) VU9-PRESMDCN
(03) VU9-PRESMDCN
(04) VU9-PRESMDCN
(05) VU9-PRESMDCN
(06) VU9-PRESMDCN
(07) VU9-PRESMDCN
(08) VU9-PRESMDCN
(09) VU9-PRESMDCN
(10) VU9-PRESMDCN
(11) VU9-PRESMDCN
(12) VU9-PRESMDCN
(13) VU9-PRESMDCN
(91) VU7A-EVOSTEXT
(-8) VU9-PRESMDCN
(-9) VU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
VU9 - PRESMDCN
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU10 - PRESFILL
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
VU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX VU3B
(02) BOX VU4
(-8) BOX VU4
(-9) BOX VU4
BOX VU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO VU10A - VUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
BOX PM3
SHOW CARD DVH2
VUPROCDR
VU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
VUPMMEDS
VU7A
VU9
VU10A
verbatim text
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[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 PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Page 11 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
(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
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
Is this medicine in the same strength, form and amount?
CODE "NO" UNLESS FORM, STRENGTH, AND AMOUNT EXACTLY MATCH PREVIOUS ROUND.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
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.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
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
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
(01) CONTINUOUS ANSWER
Page 12 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
ookup
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?
PMCOND
PMCONDOS
GETNUM
PMCOND
PMCOND
GETNUM
code one
verbatim
numeric
Medicine strength unit
Code List
(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
Routing
(01)-(08) MED-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
How many times [since (REFERENCE DATE)/between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION)] did [(you/(SP)] obtain (MEDICINE NAME)]]?
(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
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(01) CONTINUOUS ANSWER
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]
BOX PM5
Page 13 of 25
2023 MCBS Community Questionnaire
Variable Name
TABNUM
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
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
AMTUNIT
PM16
quantity unit
AMTUNOS
AMTNUM
PM16
PM16
text
numeric
BOX PM6
routing
Code List
Routing
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
(-9) REFUSED
(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) PM16 - AMTNUM
(-9) PM16 - AMTNUM
(01) CONTINUOUS ANSWER
(01) CONTINUOUS ANSWER
PM16 - AMTNUM
BOX PM6
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
TABTAKE96
PMSATVA
PM13
numeric
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) through the Department of
Veterans Affairs or V.A.?
PMSATVA
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PM13 - TABTAKE96
BOX PM7
BOX PM8
Page 14 of 25
2023 MCBS Community Questionnaire
Variable Name
PMSATHMO
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
BOX PM8
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
routing
yes/no
Did [you/(SP)] obtain (this purchase/any of these purchases) of (MEDICINE NAME) at [READ MANAGED CARE
PLAN NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN
NAME(S) BELOW]?
[PROBE: This could include obtaining the purchases at a plan pharmacy; at a pharmacy that honors [your/(SP’s)]
plan card; or through a mail order service that the managed care plan referred [you/(SP)] to.]
([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
VUMORE
PM17
yes/no
BOX VU4
routing
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO VU7-VUPROCDR.
ELSE GO TO VU14-VUMORE.
yes/no
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other eye care visits to this or any other provider?
VU14
[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?]
Code List
Routing
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX VU4
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU2 - PROVIDER_VU
(02) OM1-OMPREYEG
(-8) OM1-OMPREYEG
(-9) OM1-OMPREYEG
Next I’m going to ask you about other medical expenses related to vision care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
OMPREYEG
OM1
yes/no
(01) YES
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(02) NO
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy,
(03) INDICATED YES BY DATAPREP
replace, or pay for repairs of eyeglasses or contact lenses?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to eye care providers on (EVENT DATES) that you just
told me about.]
(01) OM1B-VUTYPE
(02) BOX VU5
(03) DO NOT DISPLAY.
(-8) BOX VU5
(-9) BOX VU5
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
VUTYPE
OM1B
code all
What did [you/(SP)] buy or repair?
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair glasses or contact lenses?
EVENT_OMEYEG OM2
roster
Please tell me all the dates [since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/between
(REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
OMADD
OM2AA
code one
(01) BUY EYEGLASS LENSES
(02) BUY EYEGLASS FRAMES
(03) BUY CONTACT LENSES
(04) REPAIR EYEGLASSES
(-8) DON'T KNOW
(-9) REFUSED
(01) continuous answer
(-8) Don't Know
(-9) Refused
MM:
DD:
YYYY:
In addition to the medical expenses related to vision care you just told me about, did [you/(SP)] buy, replace, or pay
for repairs for any other eyeglasses or contact lenses [since (REFERENCE DATE/SURVEY REFERENCE
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF (01) ADD ANOTHER
(02) ALL DONE
INSTITUTIONALIZATION/ENDUTILD)]?
OM2-EVENT_OMEYEG
BOX OM1AA
(01) OM1B - VUTYPE
(02) BOX OM1AA
[DISPLAY ALL EVENTS ENTERED]
Page 15 of 25
2023 MCBS Community Questionnaire
Variable Name
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
BOX OM1AA
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO OM2A-OMSATHMO.
ELSE GO TO BOX OM1AA2.
routing
Code List
Routing
On (EVENT DATE), did [you/(SP)] buy or repair the glasses or contact lenses at [READ MANAGED CARE PLAN
NAME(S) BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S)
BELOW]?
OMSATHMO
OM2A
yes/no
(01) YES
(02) NO
[PROBE: This could include buying or repairing the glasses or lenses at a plan center; at an optician, optometrist or (-8) Don't Know
other place that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
(-9) Refused
BOX OM1AA2
[INCLUDE NON-PRESCRIPTION READING GLASSES.]
VUNEED
BOX OM1AA2
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX VU5.
BOX VU5
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO VU15-VUNEED.
ELSE GO TO BOX VU6.
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed vision care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) VU16 - VUVNDRS
(02) BOX VU6
(-8) BOX VU6
(-9) BOX VU6
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX VU6
(02) BOX VU6
(03) BOX VU6
(04) BOX VU6
(05) BOX VU6
(06) BOX VU6
(07) BOX VU6
(08) BOX VU6
(09) BOX VU6
(10) BOX VU6
(91) VU16A - VUVNDRSOS
(-8) BOX VU6
(-9) BOX VU6
(01) continuous answer
BOX VU6
VU15
VUVNDRS
VU16
code all
What were the reasons that {you/SP} could not get the vision care {you/she/he} needed?
VUVNDRSOS
VU16A
BOX VU6
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO HU1-HUPROBE
yes/no
(01) YES
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) NO
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] go to a doctor or any other person for hearing care? [Hearing
(03) INDICATED YES BY DATAPREP
care providers include otorhinolaryngologists (ear nose and throat doctors), otologists, neurotologists, audiologists,
(-8) Don't Know
audiometrists, and hearing instrument specialists.]
(-9) Refused
HUPROBE
HU1
(01) HU2 - PROVIDER_HU
(02) HU15--OMHEARAD
(03) DO NOT DISPLAY. DATA EDITING ONLY.
(-8) OM3-OMPRHEAR
(-9) OM3-OMPRHEAR
Page 16 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
(01) [Continuous answer.]
PROVIDER_HU
HU2
roster
[DISPLAY PROVIDER ROSTER AS RESPONSE
OPTIONS:
Who did [you/(SP)] see?
1. [PROVIDER 1]
2. [PROVIDER 2]
SELECT OR ADD ONLY ONE PROVIDER.
…
N. [PROVIDER N]
ONLY SELECT "NEED TO EDIT SPELLING OF EXISTING PROVIDER" IF YOU ARE CURRENTLY ENTERING AN
N+1. ADD ANOTHER
EVENT WITH THAT PROVIDER
N+2. NEED TO EDIT SPELLING OF EXISTING
PROVIDER
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
(01-N) BOX HU1
(N+1) HU2B-PROVNAME
(N+2) CHNGSPL-CHNGSPL
IF EXISTING PROVIDER SELECTED, GO TO BOX HU1.
ELSE IF "ADD ANOTHER" SELECTED, GO TO HU2PROVNAME
ELSE IF "NEED TO EDIT SPELLING OF EXISTING
PROVIDER" SELECTED, GO TO CHNGSPL.-CHNGSPL.
ENTER THE NAME OF THE PROVIDER AND THE BILLING GROUP OR PRACTICE NAME BELOW.
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.
HPRVNAME
HU2B
verbatim text
HU2B - GRPNAME
YOU CAN CONSULT THE RESPONDENT’S STATEMENTS AND APPOINTMENT CARDS TO ENSURE THE
PROVIDER NAME IS ENTERED CORRECTLY.
[PROVIDER LOOKUP CALLED FROM THIS SCREEN]
NAME:
HGRPNAM
HU2B
verbatim text
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."
PROVSPEC
[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 OR
DISPLAY PROVIDER NAME, SPECIALITY, GROUP
ADD THE PROVIDER THE RESPONDENT SAW DURING THIS EVENT.
NAME FOR ALL PROVIDERS WHERE PROVNUM>02.
CRCTSPL
PROVSPEC
CRCTSPL
HU2C
verbatim
code one
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]
(01) [Continuous Answer]
BOX HU1
What kind of hearing care provider is [PROVNAME]?
(02) MEDICAL DOCTOR, INCLUDING
OTOLARYNGOLOGIST (ENT), OTOLOGIST,
NEUROTOLOGIST
(03) AUDIOLOGIST
(44) AUDIOMETRIST
(45) HEARING INSTRUMENT SPECIALIST
(91) OTHER
(-8) Don't Know
(-9) Refused
(02) BOX HU1
(03) BOX HU1
(44) BOX HU1
(45) BOX HU1
(91) HU2C1 - PROVSPEC
(-8) BOX HU1
(-9) BOX HU1
Page 17 of 25
2023 MCBS Community Questionnaire
Variable Name
PROVSPEC
PROVSPOS
MR Screen Name Question Type
HU2C1
HU2D
BOX HU1
VAPLACE
HU3
BOX HU2
HMOASSC
HU4
code one
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
What kind of hearing care provider is [PROVNAME]?
(01) DENTIST/DENTAL PROVIDER
(02) MEDICAL DOCTOR (DO NOT DISPLAY)
(03) AUDIOLOGIST (DO NOT DISPLAY)
(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
(19) PHYSICAL THERAPIST (PT)
(20) PHYSICIAN'S ASSISTANT
(01) BOX HU1
(02) DO NOT DISPLAY
(03) DO NOT DISPLAY
(04) BOX HU1
(05) BOX HU1
(06) BOX HU1
(07) BOX HU1
(08) BOX HU1
(09) BOX HU1
(10) BOX HU1
(11) BOX HU1
(12) BOX HU1
(13) BOX HU1
(14) BOX HU1
(15) BOX HU1
(16) BOX HU1
(17) BOX HU1
(18) BOX HU1
(19) BOX HU1
(20) BOX HU1
(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
(21) BOX HU1
(22) BOX HU1
(23) BOX HU1
(24) BOX HU1
(25) BOX HU1
(26) BOX HU1
(27) BOX HU1
(28) BOX HU1
(29) BOX HU1
(30) BOX HU1
(31) BOX HU1
(32) BOX HU1
(33) BOX HU1
(34) BOX HU1
(91) HU2D - PROVSPOS
(-8) BOX HU1
(-9) BOX HU1
(01) [Continuous answer.]
BOX HU1
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HU2
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU6 - EVENT_HU
(02) HU5 - HMOREFER
(-8) HU5 - HMOREFER
(-9) HU5 - HMOREFER
verbatim text
OTHER MEDICAL PROVIDER (SPECIFY)
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 HU3 VAPLACE.
ELSE GO TO BOX HU2.
yes/no
Is (PROVIDER NAME) associated with a Department of Veterans Affairs, or V.A., facility?
routing
IF (SP COVERED BY A MANAGED CARE PLAN ANYTIME DURING THE CURRENT ROUND) AND (IF THIS
PROVIDER IS ASSOCIATED WITH A MANAGED CARE PLAN IS UNKNOWN), GO TO HU4 - 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 HU5 - HMOREFER.
ELSE GO TO HU6 - EVENT_HU.
yes/no
Is (PROVIDER NAME) associated with [your/(SP’s)] [READ MANAGED CARE PLAN NAME(S) BELOW] plan?
Page 18 of 25
2023 MCBS Community Questionnaire
Variable Name
HMOREFR
EVENT_HU
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
Code List
Routing
HU5
[Were you/Was (SP)] referred to (PROVIDER NAME) by [READ MANAGED CARE PLAN NAME(S) BELOW]?
[INCLUDE REFERRALS BY THE SAMPLE PERSON’S PRIMARY CARE PHYSICIAN (PCP).]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
HU6 - EVENT_HU
yes/no
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.
[IF THE RESPONDENT SAW THE SAME PROVIDER TWICE ON THE SAME DAY, ENTER THE DATE ONLY
ONCE.]
MM:
DD:
YYYY:
REPEAT VISIT: YES/NO
# OF VISITS
HU6B-HUADD
(01) ADD ANOTHER
(02) ALL DONE
(01) HU6 -EVENT_HU
(02) HU7 - DVPROCDR
(01) HEARING AID FITTING/EVALUATION
(02) HEARING AID PURCHASE/REPAIR
(03) HEARING EXAM
(04) EAR WAX REMOVAL
(05) EAR VENTILATION TUBES
(06) TYMPANOPLASTY (RECONSTRUCTION OF EAR
DRUM)
(07) COCHLEAR IMPLANT SURGERY
(08) HEARING REHABILITATIVE SERVICES
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01) HU9-PRESMDCN
(02) HU9-PRESMDCN
(03) HU9-PRESMDCN
(04) HU9-PRESMDCN
(05) HU9-PRESMDCN
(06) HU9-PRESMDCN
(07) HU9-PRESMDCN
(91) HU7A-EVOSTEXT
(-8) HU9-PRESMDCN
(-9) HU9-PRESMDCN
OTHER PROCEDURE OR REASON DURING VISIT (SPECIFY)
(01) [CONTINUOUS ANSWER]
HU9 - PRESMDCN
yes/no
Were any medicines prescribed for [you/(SP)] during (this visit/any of these visits)?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU10 - PRESFILL
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
HU10
yes/no
Were any of the prescriptions filled?
[COUNT A MEDICINE AS "FILLED" REGARDLESS OF WHO OBTAINED IT FOR THE RESPONDENT,
WHETHER OR NOT THE PRESCRIPTION COST ANYTHING, AND WHETHER OR NOT THE RESPONDENT
ACTUALLY TOOK THE MEDICINE.]
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) BOX HU3B
(02) BOX HU4
(-8) BOX HU4
(-9) BOX HU4
BOX HU3B
routing
IF THE PROBE FOR PRESCRIPTION MEDICINE BOTTLES HAS NOT BEEN ASKED IN THE CURRENT ROUND,
GO TO HU10A - HUPMMEDS.
ELSE GO TO BOX PM2.
(01) INSTRUCTION WAS READ
BOX PM2
HU6
roster
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.
HUADD
HU6B
chose one
HAVE ALL DATES BEEN ENTERED?
[DISPLAY ALL EVENTS ASSOCIATED WITH THIS PROVIDER]
SHOW CARD DVH3
HUPROCDR
HU7
code all
For [your/(SP’s)] [VISIT ON EVENT DATE], what did [you/(SP)] have done?
CHECK ALL THAT APPLY.
EVOSTEXT
PRESMDCN
PRESFILL
HUPMMEDS
(01) continuous answer
(-8) Don't Know
(-9) Refused
HU7A
HU9
HU10A
verbatim text
no entry
It would be helpful if I could look at any medicine bottle(s), container(s), or bag(s) that you have so that I can spell
the medicine name correctly and enter the strength of the medicine. [Also, please take out [your/(SP's)] (MEDICARE
PRESCRIPTION DRUG PLAN NAME) medicine statements, which should have that same information on them.]
[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
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.
Page 19 of 25
2023 MCBS Community Questionnaire
Variable Name
MEDICINE_PM1
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
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 PM2A-SAMEFSAM.
ELSE GO TO PMBOTTLE-PMBOTTLE.
Code List
[DISPLAY MEDICINE ROSTER AS RESPONSE
OPTIONS:
1. [MEDICINE 1]
2. [MEDICINE 2]
…
N. [MEDICINE N]
N+1. ADD ANOTHER
[DISPLAY MEDICINE NAME, STRENGTH, FORM, AND
QUANTITY FOR EACH.
Routing
BOX PM3
CODE "YES" WITHOUT ASKING IF STATEMENT, RECEIPT, BOTTLE OR BAG IS PRESENT AND FORM,
STRENGTH AND AMOUNT ARE EXACTLY THE SAME AS IN THE PREVIOUS INTERVIEW.
At the time of the last interview, [you/(SP)] purchased (MEDICINE NAME) in the form of (MEDICINE FORM).
SAMEFSAM
SAMEFSAM
yes/no
The strength was [MEDICINE STRENGTH].
The amount in the container when it was obtained was (PREVIOUS ROUND MEDICINE AMOUNT).
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM4
(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.
BOX PM4
PMBOTTLE
PMBOTTLE
routing
IF SAMEFSAM=1/YES, THEN DO NOT CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM6AGETNUM.
ELSE, CREATE A NEW EVENT FOR THIS MEDICINE AND GO TO PM2B-PMBOTTLE.
code one
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.
PMEDNAME
MED
lookup
ONCE YOU HAVE ENTERED ALL DETAILS FOR A MEDICINE, IF YOU NEED TO GO BACK AND CORRECT,
USE THE GREEN “RETURN TO PRESCRIBED MEDICINE LOOKUP” BUTTON.
[MEDICINE NAME SELECTED FROM LOOKUP OR
MANUALLY TYPED]
[PRESCRIBED MEDICINE LOOKUP TOOL]
PMBRNAME
PMGNNAME
PMFORMFD
MED
MED
MED
lookup
lookup
lookup
[PM BRAND NAME]
[PM GENERIC NAME]
Medicine Form [FDB LIST FORM NAME]
Page 20 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
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
(01)-(12) MED-PMSTRNFD
(91) MED-PMFORMOS
PMFORMMC
MED
code one
PMFORMOS
MED
verbatim
PMFORMFN
MED
verbatim
[MEDICINE FORM OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE FORM]
PMSTRNFD
MED
verbatim
Medicine Strength
(01) [MEDICINE FORM SELECTED FROM LOOKUP]
(-7) NOT FOUND
(-8) DON'T KNOW
STRNNUMBB
MED
numeric
Medicine strength number
(01) CONTINUOUS ANSWER
STRNUNIT
MED
code one
PMSTRNOS
MED
verbatim
PMSTRUNI
MED
lookup
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
(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-PMEDID
(91) MED-PMSTRNOS
(-8) MED-PMEDID
(-9) MED-PMEDID
[MEDICINE STRENGTH UNIT OTHER SPECIFY]
[FINAL CONCATENATED MEDICINE STRENGTH]
(01) YES
(02) NO
(-9) REFUSED
(01) MED-PMEDNAME
(02) PMCOND-PMCOND
(-9) PMCOND-PMCOND
Page 21 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
PMCOND
PMCOND
code one
PMCONDOS
PMCOND
verbatim
GETNUM
TABNUM
GETNUM
numeric
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
What condition is this medicine prescribed for or what is its primary use?
IF THIS MEDICINE IS TAKEN FOR MORE THAN ONE CONDITION, SELECT ONLY ONE.
OTHER (SPECIFY)
Code List
Routing
(01) ALLERGY MEDICINE
(02) ALZHEIMERS
(03) ANTIBIOTICS
(04) ANTIPSYCHOTIC
(05) ASTHMA OR COPD
(06) BLOOD PRESSURE
(07) CHOLESTEROL
(08) COUGH AND COLD MEDICINE
(09) DEPRESSION
(10) DIABETES
(11) DIURETICS (WATER PILLS)
(12) EAR DROPS
(13) ESTROGEN
(14) EYE DROPS OR PREPARATION
(15) NASAL SPRAY/DROPS
(16) OSTEOPOROSIS (BONE LOSS)
(17) PAIN MEDICINE
(18) STEROID (GLUCOCORTICOID)
(19) STOMACH ACID OR ULCER
(91) OTHER
(-8) DON'T KNOW
(-9) REFUSED
(01)-(19) GETNUM-GETNUM
(91) PMCOND-PMCONDOS
(-8) GETNUM-GETNUM
(-9) GETNUM-GETNUM
(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)]]?
(01) continuous answer
(996) EVENT ENTERED IN ERROR
(-8) Don't Know
[IF THE MEDICINE WAS ENTERED IN ERROR AND WAS NOT OBTAINED IN THE CURRENT ROUND, CHECK
(-9) Refused
“ENTERED IN ERROR” AND LEAVE THE BOX BLANK WHERE YOU ENTER THE NUMBER OF REFILLS.]
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
(-9) REFUSED
(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) PM16 - AMTNUM
(-9) PM16 - AMTNUM
(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.
Page 22 of 25
2023 MCBS Community Questionnaire
Variable Name
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
Code List
Routing
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
TABTAKE96
PMSATVA
PMSATHMO
PM13
numeric
(01) CONTINUOUS ANSWER
(-7) EMPTY
IF LESS THAN ONE UNIT IS TAKEN PER DAY, ENTER THE APPROPRIATE DECIMAL VALUE (EX: HALF A PILL
(-8) DON'T KNOW
SHOULD BE ENTERED AS "0.5")
FOR MEDICINES TAKEN “AS NEEDED,” SELECT "TAKE AS NEEDED".
FOR MEDICINES TAKEN ON AN IRREGULAR SCHEDULE OR THAT VARY BY DAY, SELECT "OTHER DOSING
INSTRUCTIONS".
(01) DON'T TAKE EVERY DAY
(02) TAKE AS NEEDED
(03) OTHER DOSING INSTRUCTIONS
(-7) EMPTY
PM13
code one
BOX PM7
routing
IF (SP REPORTED RECEIVING HEALTH CARE SERVICES THROUGH V.A. IN THE CURRENT ROUND OR ANY
PREVIOUS ROUND), GO TO PMSATVA - PMSATVA.
ELSE GO TO BOX PM8.
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.
yes/no
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
([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
yes/no
BOX HU4
routing
[REVIEW THE INFORMATION BELOW WITH THE RESPONDENT. ASK, OR CODE AS APPROPRIATE IF R
ALREADY INDICATED: Are there any (more) medicines since (REFERENCE DATE/UTILDATE) that we haven't
talked about?]
PM13 - TABTAKE96
BOX PM7
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
BOX PM8
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED
PMMORE-PMMORE
(01) ADD ANOTHER
(02) ALL DONE
(01) BOX PM2
(02) BOX HU4
IF ANOTHER EVENT WAS ADDED WITH THIS PROVIDER, GO TO HU7-HUPROCDR.
ELSE GO TO HU14-HUMORE.
Page 23 of 25
2023 MCBS Community Questionnaire
Variable Name
HUMORE
DVH-DENTAL, VISION, AND HEARING
MR Screen Name Question Type
Question Text/Description
Code List
Routing
HU14
[Since (REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE) and (DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] have any other hearing care visits to this or any other
provider?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU2 - PROVIDER_HU
(02) HU15-OMHEARAD
(-8) HU15-OMHEARAD
(-9) HU15-OMHEARAD
yes/no
Next I’m going to ask you about other medical expenses related to hearing care that [you/(SP)] may have had
[between (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE) and (today/(DATE OF DEATH/DATE OF
INSTITUTIONALIZATION/ENDUTILD)].
OMHEARAD
HU15
yes/no
[Since (REFERENCE DATE/SURVEY REFERENCE DATE/UTILDATE)/Between (REFERENCE DATE/SURVEY
(01) YES
REFERENCE DATE) and (DATE OF DEATH/DATE OF INSTITUTIONALIZATION/ENDUTILD)], did [you/(SP)] buy, (02) NO
(03) INDICATED YES BY DATAPREP
replace, or pay for repairs of a hearing aid?
(-8) Don't Know
(-9) Refused
[Please include the purchases you made during the visit(s) to hearing care provider on (EVENT DATES) that you
just told me about.]
(01) HU16-INTHECANL
(02) BOX HU9
(03) DO NOT DISPLAY.
(-8) BOX HU9
(-9) BOX HU9
[DO NOT INCLUDE HEARING AID BATTERIES AT THIS QUESTION. ENTER HEARING AID BATTERIES IN THE
OMQ AS A HEARING/SPEECH DEVICE.]
SHOW CARD DVH4
What type of hearing aid(s) did [you/(SP)] buy or repair?
INTHCANL
HU16B
list
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU16-INTHEEAR
In the ear hearing aid
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU16-BHNDEAR
Behind the ear hearing aid
(01) LEFT EAR
(02) RIGHT EAR
(-8) Don't Know
(-9) Refued
HU17-EVENT_OMHRAD
SELECT OR ADD ALL DATES AT THIS ROSTER.
When did [you/(SP)] buy or repair the (HEARING AID ITEM)?
(01) continuous answer
(-8) Don't Know
(-9) Refused
[IF NEEDED: Were they for [your/(SP’s)] left ear, right ear, or both?]
FOR EACH DATE, CHECK ALL THAT APPLY. THE DATE WILL BE ENTERED ON THE NEXT SCREEN.
In the canal hearing aid
INTHEEAR
BHNDEAR
HU16B
HU16B
EVENT_OMHRAD HU17
OMADD
HU18
list
list
roster
code one
Please tell me the dates of each purchase or repair [since (REFERENCE DATE/SURVEY REFERENCE
MM:
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
DD:
INSTITUTIONALIZATION/ENDUTILD)].
YYYY:
In addition to the medical expenses related to hearing care you just told me about, did [you/(SP)] buy, replace, or pay
for repairs for any other hearing aids? [since (REFERENCE DATE/SURVEY REFERENCE
(01) ADD ANOTHER
DATE/UTILDATE)/between (REFERENCE DATE/SURVEY REFERENCE DATE) and (DATE OF DEATH/DATE OF
(02) ALL DONE
INSTITUTIONALIZATION/ENDUTILD)]?
HU18-OMADD
(01) HU16- INTHCANL
(02) BOX HU6
[DISPLAY ALL EVENTS ENTERED]
BOX HU6
routing
IF SP COVERED BY AN MEDICARE MANAGED CARE PLAN OR PRIVATE MANAGED CARE PLAN ANYTIME
DURING THE CURRENT ROUND, GO TO HU19-OMSATHMO.
ELSE GO TO BOX HU8.
Page 24 of 25
2023 MCBS Community Questionnaire
Variable Name
OMSATHMO
HVNEED
MR Screen Name Question Type
DVH-DENTAL, VISION, AND HEARING
Question Text/Description
On (EVENT DATE), did [you/(SP)] buy or repair the hearing aid at [READ MANAGED CARE PLAN NAME(S)
BELOW] or through a service or discount offered through [READ MANAGED CARE PLAN NAME(S) BELOW]?
Code List
Routing
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
BOX HU8
HU19
yes/no
BOX HU8
routing
IF ADMINISTERING ST, GO TO BOX ST36.
ELSE IF ADMINISTERING NS, GO TO BOX NS36.
ELSE GO TO BOX HU9.
BOX HU9
routing
IF SPALIVE=1 (ALIVE) AND SEASON=WINTER, GO TO HU20-HVNEED.
ELSE GO TO BOX HU10.
yes/no
Now thinking about all of last year, that is calendar year [CURRENT YEAR – 1], was there a time when {you/SP}
needed hearing care but could not get it at that time?
(01) YES
(02) NO
(-8) Don't Know
(-9) Refused
(01) HU21- HVNDRS
(02) BOX HU10
(-8) BOX HU10
(-9) BOX HU10
(01) COULD NOT AFFORD THE COST
(02) DID NOT WANT TO SPEND THE MONEY
(03) INSURANCE DID NOT COVER RECOMMENDED
PROCEDURES
(04) DOCTOR'S OFFICE IS TOO FAR AWAY
(05) DOCTOR'S OFFICE IS NOT OPEN AT
CONVENIENT TIMES
(06) ANOTHER DOCTOR RECOMMENDED NOT
DOING IT
(07) AFRAID OR DO NOT LIKE DOCTORS
(08) UNABLE TO TAKE TIME OFF FROM WORK
(09) TOO BUSY
(10) I DID NOT THINK ANYTHING SERIOUS WAS
WRONG/EXPECTED PROBLEMS TO GO AWAY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED
(01) BOX HU10
(02) BOX HU10
(03) BOX HU10
(04) BOX HU10
(05) BOX HU10
(06) BOX HU10
(07) BOX HU10
(08) BOX HU10
(09) BOX HU10
(10) BOX HU10
(91) HU16A - HVNDRSOS
(-8) BOX HU10
(-9) BOX HU10
(01) continuous answer
BOX HU10
HU20
[PROBE: This could include buying or repairing the hearing aid at a plan center; from an audiologist, or other
provider that honors [your/(SP’s)] plan card; or through a place or service that the plan referred [you/(SP)] to.]
HVNDRS
HU21
code all
What were the reasons that {you/SP} could not get the hearing care {you/she/he} needed?
HVNDRSOS
HU21A
BOX HU10
verbatim text
routing
WHAT OTHER REASON (SPECIFY)
GO TO EMERGENCY ROOM UTILIZATION (ERQ).
Page 25 of 25
| File Type | application/pdf |
| Author | Megan Bjorgo |
| File Modified | 2021-12-08 |
| File Created | 2021-12-08 |