CMS-P-0015A Chronic Pain

2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CPQ-CHRONIC PAIN

Question Text/Description

Code List

Routing

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

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

CHRONIC PAIN QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=INTTYPE=C001, C002, C004, C005, C006, C010
SPALIVE=1
SEASON=SUMMER
SPPROXY=SP
Other:
PLACEMENT
Administer after CVQ
SHOW CARD CP1
Now I would like to ask about your experiences with pain.
PAINOFTN

CP1

code one

In the past three months, that is since (TODAY’S MONTH AND YEAR- 3 MONTHS), how often did you have pain?
Would you say never, some days, most days, or every day?
[READ IF NECESSARY: Please answer based on your usual use of medication.]

(01) A LITTLE
(02) A LOT
(03) SOMEWHERE IN BETWEEN A LITTLE AND A LOT CP3 - PAINLIMT
Thinking about the last time you had pain, how much pain did you have? Would you say a little, a lot, or somewhere
(-8) DON’T KNOW
in between?
(-9) REFUSED
SHOW CARD CP2

PAINAMNT

CP2

code one

(01) NEVER
(02) SOME DAYS
(03) MOST DAYS
Since (TODAY'S MONTH AND YEAR - 3 MONTHS), how often did your pain limit your life or work activities? Would (04) EVERY DAY
(-8) DON’T KNOW
you say never, some days, most days, or every day?
(-9) REFUSED
SHOW CARD CP1

PAINLIMT

CP3

code one

SHOW CARD CP1
PAINFAM

CP4

code one

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

SHOW CARD CP3
PAINMANG

CP5

code one

MANGPHYS

CP6

list

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

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

MANGSPNE

CP6

list

Spinal manipulation or other forms of chiropractic care

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

CP4 - PAINFAM

CP5 - PAINMANG

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT CP6 - MANGPHYS
(-8) DON’T KNOW
(-9) REFUSED

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

CP6- MANGSPNE

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

CP6- MANGCBT

Page 1 of 3

2024 MCBS Community Questionnaire

CPQ-CHRONIC PAIN

Variable Name

MR Screen Name

Question Type

Question Text/Description

Code List

Routing

MANGCBT

CP6

list

Talk therapies such as cognitive-behavioral therapy (CBT)

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

CP6 - MANGPROG

MANGPROG

CP6

list

A chronic pain self-management program or workshop

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

CP6 - MANGGROP

MANGGROP

CP6

list

Chronic pain peer support groups

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

CP6- MANGYOGA

MANGYOGA

CP6

list

Yoga, tai chi, or qi gong

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

CP6- MANGMASG

MANGMASG

CP6

list

Massage

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

CP6- MANGMEDT

MANGMEDT

CP6

list

Meditation, guided imagery, or other relaxation techniques

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

CP7-PAINBACK

MANGCBD

CP6

grid

CBD (cannabidiol)

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

CP7-PAINBACK

SHOW CARD CP3
PAINBACK

CP7

code one

Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by...
Back pain?
Would you say not at all, a little, a lot, or somewhere in between?

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

CP8

code one

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

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
CP8- PAINARMS
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
CP9 - PAINLEGS
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

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

CP9

code one

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

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
CP10 - PAINHEAD
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

Page 2 of 3

2024 MCBS Community Questionnaire

Variable Name

MR Screen Name

Question Type

CPQ-CHRONIC PAIN

Question Text/Description

SHOW CARD CP3
PAINHEAD

CP10

code one

[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
Headache, migraine, or facial pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

SHOW CARD CP3
PAINABDM

CP11

code one

[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
Abdominal, pelvic, or genital pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

SHOW CARD CP3
PAINTOTH

CP12

code one

[Since (TODAY'S MONTH AND YEAR - 3 MONTH), how much have you been bothered by …]
Toothache or jaw pain?
[READ IF NECESSARY: Would you say not at all, a little, a lot, or somewhere in between?]

BOX CPEND

routing

Code List

Routing

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
CP11 - PAINABDM
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT
(-8) DON’T KNOW
(-9) REFUSED

(01) NOT AT ALL
(02) A LITTLE
(03) A LOT
(04) SOMEWHERE IN BETWEEN A LITTLE AND A LOT CP12 - PAINTOTH
(-8) DON’T KNOW
(-9) REFUSED

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

Go to IAQ.

Page 3 of 3