CMS-P-0015A Health_Status_and_Functioning_

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

(01) excellent,
(02) very good,
(03) good,
(04) fair, or
(05) poor?
(-8) DON'T KNOW
(-9) REFUSED

HFA2 - COMPHLTH

(01) much better now than one year ago,
(02) somewhat better now than one year ago,
(03) about the same,
(04) somewhat worse now than one year ago, or
(05) much worse now than one year ago?
(-8) DON'T KNOW
(-9) REFUSED

HFA2B - FUTRHLTH

(01) it will get much better
(02) it will get somewhat better
(03) it will not change
(04) it will get somewhat worse
(05) it will get much worse
(-8) DON'T KNOW
(-9) REFUSED

DIS1 - DISHEAR

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

DIS2 - DISSEE

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

BOX HF1

HEALTH STATUS AND FUNCTIONING QUESTIONNAIRE SPECIFICATIONS
CRITERIA
INTTYPE=C001, C002, C003, C004, C005, C006
SPALIVE=1
SEASON=FALL
SPPROXY=SP or PROXY
Other: N/A
PLACEMENT
If INTTYPE in(C001, C002, C003, C004, C005, C006), administer after PVQ.
BOX HFBEG

GENHELTH

HFA1

routing

code one

GO TO HFA1 - GENHELTH

In general, compared to other people [your/(SP's)] age, would you say that [your/his/her] health is . . .

SHOW CARD HF1
COMPHLTH

HFA2

code one

Compared to one year ago, how would you rate [your/(SP's)] health in general now?
Would you say [your/(SP's)] health is . . .

SHOW CARD HF2
FUTRHLTH

HFA2B

code one
In the next 6 months, what do you think will happen to [your/(SP's)] overall health?

Now, I would like to ask you about [your/(SP's)] health.
DISHEAR

DIS1

yes/no
[Are you/Is (SP)] deaf or [do you/does (SP)] have serious difficulty hearing?

DISSEE

DIS2

yes/no

[Are you/Is (SP)] blind or [do you/does (SP)] have serious difficulty seeing, even when wearing glasses?

BOX HF1

routing

IF P_DISTEETH=YES, GO TO DIS3-DISDECISION.
ELSE GO TO DIS2A-DISTEETH.

DISTEETH

DIS2A

yes/no

[Have you/Has (SP)] lost all of [your/his/her] upper and lower natural (permanent) teeth?

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

DIS3 - DISDECISION

DISDECISION

DIS3

yes/no

Because of a physical, mental, or emotional condition, [do you/does (SP)] have serious difficulty concentrating,
remembering, or making decisions?

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

DIS4 - DISWALK

DISWALK

DIS4

yes/no

[Do you/Does (SP)] have serious difficulty walking or climbing stairs?

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

DIS5 - DISBATH

DISBATH

DIS5

yes/no

[Do you/Does (SP)] have difficulty dressing or bathing?

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

DIS6 - DISERRANDS

Page 1 of 49

2021 MCBS Community Questionnaire

Variable Name

DISERRANDS

HELMTACT

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

DIS6

(01) YES
Because of a physical, mental, or emotional condition, [do you/does (SP)] have difficulty doing errands alone such as(02) NO
visiting a doctor's office or shopping?
(-8) DON'T KNOW
(-9) REFUSED

HFA3

yes/no

code one

How much of the time during the past month has [your/(SP's)] health limited [your/(SP's)] social activities, like
visiting with friends or close relatives?
Would you say . . .

Next we are going to ask some questions about [your/(SP's)] vision and hearing.
ECHELP

HFB1

yes/no
[Do you/Does (SP)] wear eyeglasses or contact lenses?

ECTROUB

HFB2

code one

ECLEGBLI

HFB2A

yes/no

Code List

Routing

HFA3 - HELMTACT

(01) none of the time,
(02) some of the time,
(03) most of the time, or
(04) all of the time?
(-8) DON'T KNOW
(-9) REFUSED

HFB1-ECHELP

(01) YES
(02) NO
(03) SP IS BLIND
(-8) DON'T KNOW
(-9) REFUSED

(01) HFB2 - ECTROUB
(02) HFB2 - ECTROUB
(03) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM

(01) NO TROUBLE SEEING
(02) A LITTLE TROUBLE SEEING
Which statement best describes [your/(SP's)] vision [while wearing glasses or contact lenses]... no trouble seeing, a (03) A LOT OF TROUBLE SEEING
little trouble, a lot of trouble, or no usable vision?
(04) NO USABLE VISION
(-8) DON'T KNOW
(-9) REFUSED

(01) YES
(02) NO
[EXPLAIN IF NECESSARY: Informally, a person is legally blind when, even with corrective lenses, they cannot see (-8) DON'T KNOW
well enough to drive.]
(-9) REFUSED

(01) HFB6 - EDOCEXAM
(02) HFB6 - EDOCEXAM
(03) HFB2A - ECLEGBLI
(04) HFB6 - EDOCEXAM
(-8) HFB6 - EDOCEXAM
(-9) HFB6 - EDOCEXAM

[Have you/Has (SP)] been told that [you are/he is/she is] legally blind?

[Have you/Has (SP)] had an eye examination by an eye doctor since (LAST HF MONTH YEAR)?
EDOCEXAM

HFB6

yes/no

INCLUDE OPHTHALMOLOGISTS AND OPTOMETRISTS.

routing

IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFB7-EDOCLAST.
ELSE GO TO BOX HFB1.

[IF NEEDED: Please include any eye exams that took place during a visit that you may have already told me about.]
BOX HFC

EDOCLAST

HFB7

code one

How long has it been since [your/(SP's)] last eye examination by an eye doctor?

HFB6 - EDOCEXAM

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

(01) HFB7A - EDOCTYPE
(02) BOX HFC
(-8) BOX HFB1
(-9) BOX HFB1

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

(996) BOX HFB1
(01) - (12) HFB7A - EDOCTYPE
(-8) BOX HFB1
(-9) BOX HFB1

I have a couple of questions about [your/(SP’s)] last eye examination.
(01) OPTOMETRIST
(02) OPHTHALMOLOGIST
(91) OTHER DOCTOR SPECIALTY
(-8) DON'T KNOW
[EXPLAIN IF NECESSARY: An optometrist is a doctor of optometry (O.D.) who diagnoses and treats visual health (-9) REFUSED
problems. An ophthalmologist is a doctor of medicine (M.D.) who specializes in surgery and diseases of the eye.]

(01) H7B7B - EDOCDLAT
(02) H7B7B - EDOCDLAT
(91) HFB7 - EDOCTYOS
(-8) BOX HFB1
(-9) BOX HFB1

H7B7B - EDOCDLAT

EDOCTYPE

HFB7A

code one

Was the eye examination given by an optometrist, ophthalmologist or some other type of doctor or eye care
professional?

EDOCTYOS

HFB7A

verbatim text

OTHER (SPECIFY)
Again, thinking about [your/(SP’s)] last eye examination, were dilating drops used in [your/(SP)’s] eyes?

EDOCDLAT

HFB7B

yes/no

[EXPLAIN IF NECESSARY: Dilating drops are used to enlarge the pupil for eye examinations. The drops often
make your eyes more sensitive to bright light and may cause temporary blurry vision.]

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

HFB7C - ECATARAC

Page 2 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

ECATARAC

HFB7C

yes/no

I am going to read a list of eye conditions. Please tell me if [you have/(SP) has] ever been told by a doctor or other
health professional that [you/he/she] had any of these conditions.
(01) YES
(02) NO
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-8) DON'T KNOW
(-9) REFUSED
Cataracts?

EGLAUCOM

HFB7C

yes/no

Glaucoma?

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

HFB7C - ERETINOP

ERETINOP

HFB7C

yes/no

Diabetic retinopathy?

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

HFB7C - EMACULAR

EMACULAR

HFB7C

yes/no

Macular degeneration or age-related macular degeneration, also called AMD?

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

BOX HFB1A

BOX HFB1A

routing

IF ECATARAC=02/NO, GO TO BOX HFB1. ELSE GO TO HFB10 - ECCATOP.

HFB10

yes/no

[Have you/Has (SP)] ever had an operation for cataracts?

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

BOX HFB1

BOX HFB1

routing

IF HFB7C - ERETINOP = 1/Yes OR HFB7C - EMACULAR = 1/Yes, GO TO HFB11 - ELASRSUR.
ELSE GO TO HFC1 - HCHELP.
(01) YES
(02) NO
(-8) DON'T KNOW
(-9) REFUSED

HFC1 - HCHELP

(01) YES
(02) NO
(03) SP IS DEAF
(-8) DON'T KNOW
(-9) REFUSED

(01) HFC2 - HCTROUB
(02) HFC2 - HCTROUB
(03) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL

ECCATOP

Laser surgery to the back of the eye, or retina, is a commonly used treatment for diabetic retinopathy and macular
degeneration.
ELASRSUR

HFB11

yes/no

[Have you/Has (SP)] ever had laser surgery to the back of either eye for one of these conditions?

Code List

Routing

HFB7C - EGLAUCOM

[EXPLAIN IF NECESSARY: This does not include "Lasik" surgery to the front of the eye used to correct vision.]

HCHELP

HFC1

yes/no

[Do you/Does (SP)] use a hearing aid?

HCTROUB

HFC2

code one

(01) NO TROUBLE HEARING
(02) A LITTLE TROUBLE HEARING
Which statement best describes [your/(SP's)] hearing [with a hearing aid]: no trouble hearing, a little trouble, a lot of (03) A LOT OF TROUBLE HEARING
trouble, or deaf?
(04) DEAF
(-8) DON'T KNOW
(-9) REFUSED

HCKNOWMC

HFC3

code one

How much trouble [do you/does (SP)] have finding out things [you need/he needs/she needs] to know about
Medicare because [of (your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would you say [you have/she
has/he has] no trouble, a little trouble, or a lot of trouble?

(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED

HFC4 - HCCOMDOC

HCCOMDOC

HFC4

code one

(01) NO TROUBLE
How much trouble [do you/does (SP)] have communicating with [your/his/her] doctor or other health professional
(02) A LITTLE TROUBLE
because [of (your/his/her) difficulty hearing/(you are/he is/she is) deaf]? Would you say [you have/she has/he has] (03) A LOT OF TROUBLE
no trouble, a little trouble, or a lot of trouble?
(-8) DON'T KNOW
(-9) REFUSED

HFD1A - FOODTRBL

(01) NO TROUBLE
(02) A LITTLE TROUBLE
(03) A LOT OF TROUBLE
(-8) DON'T KNOW
(-9) REFUSED

HFE1 - HEIGHTFT

(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED

HFE1 - HEIGHTIN

FOODTRBL

HFD1A

code one

How much trouble [do you/does (SP)] have eating solid foods because of problems with [your/his/her] mouth or
teeth? Would you say [you have/she has/he has] no trouble, a little trouble, or a lot of trouble?

HEIGHTFT

HFE1

numeric

How tall [are you/is (SP)]?

(01) HFD1A - FOODTRBL
(02) HFC3 - HCKNOWMC
(03) HFC3 - HCKNOWMC
(04) HFC3 - HCKNOWMC
(-8) HFD1A - FOODTRBL
(-9) HFD1A - FOODTRBL

Page 3 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HEIGHTIN

HFE1

numeric

WEIGHT

HFE1

numeric

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

How tall [are you/is (SP)]?

(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED

HFE1 - WEIGHT

(01) continuous answer
(-8) DON'T KNOW
(-9) REFUSED

HFHINTRO - DIFINTRO
LOSTWGHT

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

EATLESWK

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

HFHINTRO - DIFINTRO

How much [do you/does (SP)] weigh?
[WEIGHT SHOULD BE RECORDED IN POUNDS]

[Have you/Has (SP)] lost weight in the past 6 months without trying to lose this weight?
LOSTWGHT

LOSTWGHT

yes/no

IF RESPONDENT REPORTS A WEIGHT LOSS BUT THE WEIGHT WAS GAINED BACK, CONSIDER IT AS NO
WEIGHT LOSS.
[IF NEEDED: Is [your/(SP)'s] clothing fitting more loosely?]

[Have you/Has (SP)] been eating less than usual for more than a week?
EATLESWK

EATLESWK

yes/no

DIFINTRO

HFHINTRO

no entry

IF THE RESPONDENT REPORTS THAT THEY HAVE INTENTIONALLY BEEN EATING LESS (DIETING,
FASTING, ETC.) SELECT "YES" AT THIS SCREEN

Now, I'm going to ask about how difficult it is, on average, for [you/(SP)] to do certain kinds of activities. Please tell
(01) CONTINUE
me for each activity whether [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a lot of difficulty,
(-7) Empty
or [is/are] not able to do it.

SHOW CARD HF3
DIFSTOOP

HFH1

code 1

How much difficulty, if any, [do you/does (SP)] have stooping, crouching, or kneeling? Would you say [you
have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a lot of difficulty, or [is/are] not able to do it?

(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
(-8) Don't Know
(-9) Refused

HFH1 - DIFSTOOP

HFH2 - DIFLIFT

SHOW CARD HF3

DIFLIFT

HFH2

code 1

(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a (-8) Don't Know
lot of difficulty, or [is/are] not able to do it?]
(-9) Refused

HFH3 - DIFREACH

(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
What about reaching or extending arms above shoulder level?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
(-8) Don't Know
lot of difficulty, or [is/are] not able to do it?]
(-9) Refused

HFH4 - DIFWRITE

(01) NO DIFFICULTY AT ALL
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
How much difficulty, if any, [do you/does (SP)] have either writing or handling and grasping small objects?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
(-8) Don't Know
lot of difficulty, or [is/are] not able to do it?]
(-9) Refused

HFH5 - DIFWALK

How much difficulty, if any, [do you/does (SP)] have lifting or carrying objects as heavy as 10 pounds, like a heavy
bag of groceries?

SHOW CARD HF3
DIFREACH

HFH3

code 1

SHOW CARD HF3
DIFWRITE

HFH4

code 1

Page 4 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

Code List

DIFWALK

HFH5

code 1

(01) NO DIFFICULTY AT ALL
SHOW CARD HF3
(02) A LITTLE DIFFICULTY
(03) SOME DIFFICULTY
What about walking a quarter of a mile - that is, about 2 or 3 blocks?
(04) A LOT OF DIFFICULTY
(05) NOT ABLE TO DO IT
[PROBE IF NECESSARY: Would you say [you have/(SP) has] no difficulty at all, a little difficulty, some difficulty, a
(-8) Don't Know
lot of difficulty, or [is/are] not able to do it?]
(-9) Refused

HFH10INT - PHYSACTINTRO

PHYSACTINTRO

HFH10INT

no entry

We are interested in two types of physical activity - vigorous and moderate. Vigorous activities cause large
increases in breathing or heart rate. Moderate activities cause small increases in breathing or heart rate. First I will
ask about the vigorous activities that [you do/(SP) does].

HFH10 - VIGUNIT

(01) HFH10 - VIGNUM
(02) HFH10 - VIGNUM
(03) HFH10 - VIGNUM
(04) HFH10 - VIGNUM
(96) HFH11 - MODUNIT
(-8) HFH11 - MODUNIT
(-9) HFH11 - MODUNIT

HFH11 - MODUNIT

(01) CONTINUE
(-7) Empty

VIGUNIT

HFH10

quantity unit

(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
In a typical week, how much time [do you/does (SP)] spend doing vigorous activities, such as team sports, running,
(03) NUMBER OF HOURS PER WEEK
aerobics, heavy house or yard work, or anything else that causes large increases in breathing or heart rate?
(04) NUMBER OF HOURS PER MONTH
(96) NONE
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.
(-8) Don't Know
(-9) Refused

VIGNUM

HFH10

quantity unit

In a typical week, how much time [do you/does (SP)] spend doing vigorous activities, such as team sports, running,
(01) [Continuous answer.]
aerobics, heavy house or yard work, or anything else that causes large increases in breathing or heart rate?
(-8) Don't Know
(-9) Refused
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.

MODUNIT

HFH11

quantity unit

In a typical week, how much time [do you/does (SP)] spend doing moderate activities, such as brisk walking,
bicycling, gardening, golf, swimming, or vacuuming?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.

MODNUM

HFH11

numeric

In a typical week, how much time [do you/does (SP)] spend doing moderate activities, such as brisk walking,
bicycling, gardening, golf, swimming, or vacuuming?

Now I’m going to ask you about activities [you/(SP)] may do to increase [your/(SP)'s] muscle strength or flexibility.
MUSUNIT

HFH12

quantity unit

In a typical week, how much time [you/(SP)] spend doing exercises to increase [your/(SP)'s] muscle strength or
flexibility, such as lifting weights, push-ups, sit-ups, stretching, or yoga?
IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.

MUSNUM

HFH12

numeric

In a typical week, how much time [you/(SP)] spend doing exercises to increase [your/(SP)'s] muscle strength or
flexibility, such as lifting weights, push-ups, sit-ups, stretching, or yoga?

Routing

(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused

(01) HFH11 - MODNUM
(02) HFH11 - MODNUM
(03) HFH11 - MODNUM
(04) HFH11 - MODNUM
(96) HFH12 - MUSUNIT
(-8) HFH12 - MUSUNIT
(-9) HFH12 - MUSUNIT

(01) continous answer

(01) HFH12 - MUSUNIT

(01) NUMBER OF MINUTES PER DAY
(02) NUMBER OF HOURS PER DAY
(03) NUMBER OF HOURS PER WEEK
(04) NUMBER OF HOURS PER MONTH
(96) NONE
(-8) Don't Know
(-9) Refused

(01) HFH12 - MUSNUM
(02) HFH12 - MUSNUM
(03) HFH12 - MUSNUM
(04) HFH12 - MUSNUM
(96) HFJINTRO - MEDCONDINTRO
(-8) HFJINTRO - MEDCONDINTRO
(-9) HFJINTRO - MEDCONDINTRO

(01) Continunous answer

HFJINTRO - MEDCONDINTRO

(01) CONTINUE
(-7) Empty

BOX HFJ1

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

HFJ2 - OCHBP

IF TIME REPORTED IN BOTH MINUTES AND HOURS, ROUND TO NEAREST HOUR.

Next, I'm going to read a list of medical conditions. [Since (LAST HF MONTH YEAR) has/Has] a doctor or other
health professional [ever] told [you/(SP)] that [you/he/she] had any of these conditions?
MEDCONDINTRO HFJINTRO

no entry
[INTERVIEWER: IF THE SP IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, THE
RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE SP HAS THE CONDITION.]

OCARTERY

BOX HFJ1

routing

HFJ1

yes/no

IF SP HAS EVER REPORTED HAVING HARDENING OF THE ARTERIES IN A PREVIOUS ROUND
(sample_person.P_OCARTERY=1), GO TO HFJ2 - OCHBP.
ELSE GO TO HFJ1 - OCARTERY.
[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...
hardening of the arteries or arteriosclerosis?

Page 5 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] [still has/still have/had/has/have...]

OCHBP

HFJ2

yes/no

hypertension, sometimes called high blood pressure?
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION,
THE RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]

BOX HFJ2

routing

Code List

Routing

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

(01) BOX HFJ2
(02) HFJ4 - OCMYOCAR
(-8) HFJ4 - OCMYOCAR
(-9) HFJ4 - OCMYOCAR

IF SP IS IN THE SUPPLEMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ3 - YRHBP.
ELSE GO TO HFJ4 - OCMYOCAR.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] still had
hypertension or high blood pressure?

YRHBP

HFJ3

yes/no

OCMYOCAR

HFJ4

yes/no

(01) YES
(02) NO
(-8) Don't Know
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION,
(-9) Refused
THE RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
a myocardial infarction or heart attack?

BOX HFJ3

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ5 - YRMYOCAR.
ELSE GO TO HFJ6 - OCCHD.

YRMYOCAR

HFJ5

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
myocardial infarction or heart attack?

OCCHD

HFJ6

yes/no

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] angina pectoris or coronary heart disease?

BOX HFJ4

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ7 - YRCHD.
ELSE GO TO HFJ8 - OCCFAIL.

YRCHD

HFJ7

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
episode of angina pectoris or coronary heart disease?

OCCFAIL

HFJ8

yes/no

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] congestive heart failure?

YRCFAIL

BOX HFJ5

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ9 - YRCFAIL.
ELSE GO TO HFJ14 - OCHRTCND.

HFJ9

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell[you/(SP)] that [you/he/she] had an
episode of congestive heart failure?

HFJ4 - OCMYOCAR

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

(01) BOX HFJ3
(02) HFJ6 - OCCHD
(-8) HFJ6 - OCCHD
(-9) HFJ6 - OCCHD

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

HFJ6 - OCCHD

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

(01) BOX HFJ4
(02) HFJ8 - OCCFAIL
(-8) HFJ8 - OCCFAIL
(-9) HFJ8 - OCCFAIL

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

HFJ8 - OCCFAIL

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

(01) BOX HFJ5
(02) HFJ14 - OCHRTCND
(-8) HFJ14 - OCHRTCND
(-9) HFJ14 - OCHRTCND

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

HFJ14 - OCHRTCND

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
[a new episode of] any other heart condition?
OCHRTCND

HFJ14

yes/no
[NOTE TO FI: This includes problems with the valves of the heart, such as aortic stenosis, and problems with the
rhythm of the heartbeat, such as atrial fibrillation.]

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

(01) BOX HFJ8
(02) HFJ16 - OCSTROKE
(-8) HFJ16 - OCSTROKE
(-9) HFJ16 - OCSTROKE

[DO NOT RECORD THE NAME OF THE CONDITION AT THIS QUESTION.]

Page 6 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

BOX HFJ8

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ15 - YRHRTCND.
ELSE GO TO HFJ16 - OCSTROKE.

routing

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
episode of any other heart condition?
YRHRTCND

HFJ15

yes/no
[NOTE TO FI: This includes problems with the valves of the heart, such as aortic stenosis, and problems with the
rhythm of the heartbeat, such as atrial fibrillation.]

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
OCSTROKE

HFJ16

yes/no

a stroke, a brain hemorrhage, or a cerebrovascular accident?
[NOTE: This includes transient ischemic attack (TIA) which is sometimes referred to as a ministroke.]

YRSTROKE

BOX HFJ9

routing

HFJ17

yes/no

Code List

Routing

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

HFJ16 - OCSTROKE

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

(01) BOX HFJ9
(02) HFJ17A - OCCHOLES
(-8) HFJ17A - OCCHOLES
(-9) HFJ17A - OCCHOLES

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

HFJ17A - OCCHOLES

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ17 - YRSTROKE.
ELSE GO TO HFJ17A - OCCHOLES.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
stroke, a brain hemorrhage, or a cerebrovascular accident?
[NOTE: This includes transient ischemic attack (TIA) which is sometimes referred to as a ministroke.]

OCCHOLES

HFJ17A

yes/no

Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had high cholesterol?

(01) YES
(02) NO
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION, (-8) Don't Know
THE RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]
(-9) Refused

(01) HFJ17B - YRCHOLES
(2) BOX HFJ29
(-8) BOX HFJ29
(-9) BOX HFJ29

YRCHOLES

HFJ17B

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had high
(01) YES
cholesterol?
(02) NO
(-8) Don't Know
[INTERVIEWER: IF THE RESPONDENT IS CURRENTLY TAKING MEDICATION TO CONTROL A CONDITION,
(-9) Refused
THE RESPONSE RECORDED SHOULD BE "YES" TO INDICATE THAT THE R HAS THE CONDITION.]

BOX HFJ29

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO HFJ45-BLOSWGHT.
ELSE IF be P_EVRLWGHT ^= YES THEN GO TO HFJ46-CLOSWGHT.
ELSE GO TO HFJ18 - OCCSKIN.

BOX HFJ29

BLOSWGHT

HFJ45

yes/no

To lower risk for certain diseases, [have you/ has (SP)] ever been told by a doctor or health professional to control
weight or lose weight?

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

HFJ18 - OCCSKIN

CLOSWGHT

HFJ46

yes/no

(01) YES
To lower risk for certain diseases, since (SAMPLE_PERSON.DATE_FALLRND) [have you/ has (SP)] been told by a(02) NO
doctor or health professional to control weight or lose weight?
(-8) Don't Know
(-9) Refused

HFJ18 - OCCSKIN

[I've recorded that [you/(SP)] previously reported having had skin cancer.]
OCCSKIN

HFJ18

yes/no

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]

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

(01) BOX HFJ10
(02) HFJ20 - EVRCANCR
(-8) HFJ20 - EVRCANCR
(-9) HFJ20 - EVRCANCR

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

HFJ20 - EVRCANCR

[a new occurrence of] skin cancer?

YRCSKIN

BOX HFJ10

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ19 - YRCSKIN.
ELSE GO TO HFJ20 - EVRCANCR.

HFJ19

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had an
occurrence of skin cancer?

Page 7 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[I've recorded that [you/(SP)] previously reported having had a tumor, growth, malignancy, or cancer of the [READ
RESPONSES BELOW].]

EVRCANCR

HFJ20

yes/no

[Since (LAST HF MONTH YEAR), has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had any [other] kind of cancer, malignancy, or tumor other than skin cancer?

Code List

Routing

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

(01) BOX HFJ11
(02) BOX HFJ13
(-8) BOX HFJ13
(-9) BOX HFJ13

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

HFJ22 - OCCCODE

DO NOT INCLUDE BENIGN OR NON-MALIGNANT TUMORS OR GROWTHS.

YRCANCER

BOX HFJ11

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE [sample_person.INTTYPE=3], GO TO HFJ21 - YRCANCER.
ELSE GO TO HFJ22 - OCCCODE.

HFJ21

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had any
kind of cancer, malignancy, or tumor other than skin cancer?

(01) BOX HFJ13
(02) BOX HFJ13
(03) BOX HFJ13
(04) BOX HFJ13
(05) BOX HFJ13
(06) BOX HFJ13
(07) BOX HFJ13
(08) BOX HFJ13
(09) BOX HFJ13
(10) BOX HFJ13
(11) BOX HFJ13
(12) BOX HFJ13
(16) BOX HFJ13
(17) BOX HFJ13
(18) BOX HFJ13
(19) BOX HFJ13
(20) BOX HFJ13
(21) BOX HFJ13
(22) BOX HFJ13
(23) BOX HFJ13
(24) BOX HFJ13
(25) BOX HFJ13
(26) BOX HFJ13
(27) BOX HFJ13
(28) BOX HFJ13
(29) BOX HFJ13
(91) HFJ22 - OCCOS
(-8) BOX HFJ13
(-9) BOX HFJ13

(01) [Continuous answer.]

BOX HFJ13

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

(01) BOX HFJ15
(02) BOX HFJ16
(-8) BOX HFJ16
(-9) BOX HFJ16

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

BOX HFJ14

OCCCODE

HFJ22

code all

(06) BLADDER
(16) BLOOD
(17) BONE
(10) BRAIN
(03) BREAST
(09) CERVIX
(02) COLON (BOWEL)
(18) ESOPHAGUS
(19) GALL BLADDER
(11) KIDNEY
(20) LARYNX (WINDPIPE)
SHOW CARD HF4
(21) LEUKOCYTES (LEUKEMIA)
(22) LIVER
[Since the first time a doctor or other health professional told [you/(SP)] that [you/he/she] had a cancer, malignancy, (01) LUNG
or tumor, on/On] what part or parts of [your/(SP's)] body was the cancer or tumor other than skin cancer found?
(23) LYMPH NODES (LYMPHOMA)
(24) MOUTH/TONGUE/LIP
[PROBE: Any other part?]
(07) OVARY
CHECK ALL THAT APPLY
(25) PANCREAS
(05) PROSTATE
(26) RECTUM
(27) SOFT TISSUE/FAT
(08) STOMACH
(28) TESTIS
(12) THROAT
(29) THYROID
(04) UTERUS
(91) OTHER
(-8) Don't Know
(-9) Refused

OCCOS

HFJ22

verbatim text

Specify the part of parts of your body where the cancer or tumor was found.

BOX HFJ13

routing

IF SP HAS EVER REPORTED HAVING RHEUMATOID ARTHRITIS IN A PREVIOUS ROUND
(sample_person.P_OCARTHRH=1), GO TO BOX HFJ13B.
ELSE GO TO HFJ24 - OCARTHRH.

HFJ24

yes/no

OCARTHRH

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
rheumatoid arthritis?

OCOSARTH

BOX HFJ13B

routing

HFJ24B

yes/no

IF SP HAS EVER REPORTED HAVING OSTEOARTHRITIS IN A PREVIOUS ROUND
(sample_person.P_OCOSARTH=1), GO TO BOX HFJ14.
ELSE GO TO HFJ24B-OCOSARTH.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
osteoarthritis?

BOX HFJ14

routing

IF SP HAS EVER REPORTED HAVING ARTHRITIS OTHER THAN RHEUMATOID ARTHRITIS IN A PREVIOUS
ROUND [sample_person.P_OCARTH=1], GO TO BOX HFJ16.
ELSE GO TO HFJ25 - OCARTH.

Page 8 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
(you/he/she) had...]

OCARTH

YRARTHRD

HFJ25

yes/no

BOX HFJ15

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE, GO TO HFJ26 - YRARTHRD.
ELSE GO TO BOX HFJ16A.

HFJ26

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
arthritis, other than rheumatoid or osteoarthritis, in any part of [your/his/her] body?

BOX HFJ16

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ28 - OCMENTAL.
ELSE GO TO BOX HFJ16A.

arthritis, other than rheumatoid or osteoarthritis?

Code List

Routing

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

(01) BOX HFJ15
(02) BOX HFJ16
(-8) BOX HFJ16
(-9) BOX HFJ16

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

BOX HFJ16

[Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had...]
OCMENTAL

OCALZMER

HFJ28

yes/no

BOX HFJ16A

routing

HFJ29A

yes/no

(01) YES
(02) NO
(-8) Don't Know
[EXPLAIN IF NECESSARY:] This is also known as intellectual development disorder or a general learning disability. (-9) Refused
It was formerly known as mental retardation.
an intellectual disability?

IF SP HAS EVER REPORTED HAVING ALZHEIMER’S DISEASE IN A PREVIOUS ROUND
(sample_person.P_OCALZMER=1), GO TO BOX HFJ16B.
ELSE GO TO HFJ29A - OCALZMER.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
Alzheimer's disease?

OCDEMENT

BOX HFJ16B

routing

HFJ29B

yes/no

BOX HFJ16A

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

(01) BOX HFJ16B
(02) BOX HFJ16B
(-8) BOX HFJ16B
(-9) BOX HFJ16B

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

BOX HFJ30

IF SP HAS EVER REPORTED HAVING DEMENTIA IN A PREVIOUS ROUND (sample_person.P_OCDEMENT=1),
GO TO BOX HFJ30
ELSE GO TO HFJ29B - OCDEMENT.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
any type of dementia other than Alzheimer's disease?

BOX HFJ30

routing

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) GO TO HFJ47-BASKDEPRS.
ELSE IF P_EVRDPRSS ^= YES THEN GO TO HFJ48-CASKDEPRS.
ELSE GO TO HFJ30AA - OCDEPRSS.

BASKDEPRS

HFJ47

yes/no

(01) YES
Has a doctor or other health professional ever asked [you/(SP)] if there was a period of time when [you/he/she] felt (02) NO
sad, empty, or depressed?
(-8) Don't Know
(-9) Refused

HFJ30AA - OCDEPRSS

CASKDEPRS

HFJ48

yes/no

Since (SAMPLE_PERSON.DATE_FALLRND), has a doctor or other health professional asked [you/(SP)] if there
was a period of time when [you/he/she] felt sad, empty, or depressed?

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

HFJ30AA - OCDEPRSS

OCDEPRSS

HFJ30AA

yes/no

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

(01) BOX HFJ17A
(02) HFJ30A - OCPSYCHO
(-8) HFJ30A - OCPSYCHO
(-9) HFJ30A - OCPSYCHO

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

HFJ30A - OCPSYCHO

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
depression?

YRDEPRSS

BOX HFJ17A

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ30BB - YRDEPRSS.
ELSE GO TO HFJ30A - OCPSYCHO.

HFJ30BB

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
depression?

Page 9 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]

OCPSYCHO

HFJ30A

yes/no

a mental or psychiatric disorder other than depression?

Code List

Routing

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

(01) BOX HFJ17B
(02) BOX HFJ19
(-8) BOX HFJ19
(-9) BOX HFJ19

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

BOX HFJ19

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

HFJ33 - OCBRKHIP

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

(01) BOX HFJ20
(02) BOX HFJ21
(-8) BOX HFJ21
(-9) BOX HFJ21

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

BOX HFJ21

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

BOX HFJ22

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

HFJ37 - OCPPARAL

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

(01) BOX HFJ23
(02) BOX HFJ24
(-8) BOX HFJ24
(-9) BOX HFJ24

[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]

YRPSYCHO

BOX HFJ17B

routing

HFJ31A

yes/no

IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ31A - YRPSYCHO.
ELSE GO TO BOX HFJ19.
Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
mental or psychiatric disorder other than depression?
[INCLUDE ALCOHOLISM AS A MENTAL OR PSYCHIATRIC DISORDER.]

OCOSTEOP

BOX HFJ19

routing

HFJ32

yes/no

IF SP HAS EVER REPORTED HAVING OSTEOPOROSIS IN A PREVIOUS ROUND
(sample_person.P_OCOSTEOP=1), GO TO HFJ33 - OCBRKHIP.
ELSE GO TO HFJ32 - OCOSTEOP.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
osteoporosis, sometimes called fragile or soft bones?
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]]

OCBRKHIP

HFJ33

yes/no
a broken hip?

YRBRKHIP

OCPARKIN

BOX HFJ20

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFJ34 - YRBRKHIP.
ELSE GO TO BOX HFJ21.

HFJ34

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had a
broken hip?

BOX HFJ21

routing

IF SP HAS EVER REPORTED HAVING PARKINSON’S DISEASE IN A PREVIOUS ROUND
(sample_person.P_OCPARKIN=1), GO TO BOX HFJ22.
ELSE GO TO HFJ35 - OCPARKIN.

HFJ35

yes/no

[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
Parkinson's disease?

BOX HFJ22

routing

IF SP HAS EVER REPORTED HAVING EMPHYSEMA, ASTHMA OR COPD IN A PREVIOUS ROUND
(sample_person.P_OCEMPHYS=1), GO TO HFJ37 - OCPPARAL.
ELSE GO TO HFJ36 - OCEMPHYS.
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]

OCEMPHYS

HFJ36

yes/no

emphysema, asthma, or COPD?
COPD=CHRONIC OBSTRUCTIVE PULMONARY DISEASE

OCPPARAL

HFJ37

yes/no

IF SP IS OBVIOUSLY PARTIALLY OR COMPLETELY PARALYZED, SELECT "YES" AND DO NOT ASK.
OTHERWISE, ASK:
[[Since (LAST HF MONTH YEAR) has/Has] a doctor or other health professional [ever] told [you/(SP)] that
[you/he/she] had...]
complete or partial paralysis?

BOX HFJ23

routing

IF SP IS IN THE SUPPLMENTAL SAMPLE (sample_person.INTTYPE=3, GO TO HFJ38 - YRPPARAL.
ELSE GO TO BOX HFJ24.

Page 10 of 49

2021 MCBS Community Questionnaire

Variable Name

YRPPARAL

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

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

BOX HFJ24

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

BOX HFJ25

HFJ38

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he/she] had
complete or partial paralysis?

BOX HFJ24

routing

IF SP HAS EVER REPORTED AN ABSENCE OR LOSS OF ARM OR LEG IN A PREVIOUS ROUND
(sample_person.P_OCAMPUTE=1), GO TO BOX HFJ25.
ELSE GO TO HFJ39 - OCAMPUTE.

HFJ39

yes/no

IF SP IS OBVIOUSLY MISSING ONE OR MORE LIMBS, SELECT "YES" AND DO NOT ASK. OTHERWISE, ASK:
OCAMPUTE

What about absence or loss of an arm or a leg?

BOX HFJ25

routing

IF SP IS FEMALE (ROSTSEX=2 or (roster.ROSTSEX=2 where ROSTNUM=1)), GO TO BOX HFCI.
ELSE GO TO HFJ40 - HAVEPROS.

HFJ40

yes/no

[[Before (you/[SP]) had prostate surgery, did a doctor or other health professional ever tell/Since (LAST HF MONTH (01) YES
YEAR), has/Has] a doctor or other health professional [ever] told [you/(SP)] that [you/he] had...]
(02) NO
(-8) Don't Know
an enlarged prostate or benign prostatic hypertrophy (BPH)?
(-9) Refused

BOX HFJ26

routing

IF SP IS IN THE BASELINE SAMPLE (sample_person.INTTYPE=3), GO TO HFJ41 - YRPROST.
ELSE GO TO BOX HFCI.

HFJ41

yes/no

Since (LAST HF MONTH YEAR), did a doctor or other health professional tell [you/(SP)] that [you/he] had an
enlarged prostate or benign prostatic hypertrophy (BPH)?

BOX HFCI

routing

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP16AOCKIDNY.
ELSE IF P_DKIDNY ^= YES, GO TO YRKID-YRKID.
ELSE GO TO HFCA.

OCKIDNY

HFP16A

yes/no

(01) YES
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you have/she has/he has] chronic (02) NO
kidney disease?
(-8) Don't Know
(-9) Refused

YRKID

YRKID

yes/no

Since [SAMPLE_PERSON.DATE_FALLRND], [Have you/Has (SP)] been told by a doctor or other health
professional that [you have/she has/he has] chronic kidney disease?

BOX HFCA

routing

IF P_OCBETES=YES, GO TO BOX HFCB.
ELSE IF SP IS IN THE BASELINE SAMPLE (sample_person.INTTYPE=3), GO TO HFJ41A-OCBETES.
ELSE GO TO YRBETES-YRBETES.

HFJ41A

yes/no

Has a doctor or other health professional ever told [you/(SP)] that [you/he/she] had any type of diabetes, including: (01) YES
(02) NO
sugar diabetes, high blood sugar, [borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline
(-8) Don't Know
diabetes, or pre-diabetes]?
(-9) Refused

HAVEPROS

YRPROST

OCBETES

Since [SAMPLE_PERSON.DATE_FALLRND], has a doctor or other health professional told [you/(SP)] that
[you/he/she] had any type of diabetes, including:
YRBETES

YRBETES

yes/no
sugar diabetes, high blood sugar, [borderline diabetes, pre-diabetes, or pregnancy-related diabetes/borderline
diabetes, or pre-diabetes]?

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

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

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

(01) BOX HFJ26
(02) BOX HFCI
(-8) BOX HFCI
(-9) BOX HFCI

BOX HFCI

BOX HFCA

BOX HFCA

(01) HFJ41B - OCDTYPE
(02) BOX HFJ27
(-8) BOX HFJ27
(-9) BOX HFJ27

(01) HFJ41B - OCDTYPE
(02) BOX HFJ27
(-8) BOX HFJ27
(-9) BOX HFJ27

Page 11 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

SHOW CARD HF5
(01) TYPE 1
(02) TYPE 2
(03) BORDERLINE
[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT (04) PRE-DIABETES
(05) GESTATIONAL (PREGNANCY-RELATED)
TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]
(91) SOME OTHER TYPE
[EXPLAIN IF NECESSARY: “Type 1” was formerly called “insulin dependent” or “juvenile-onset” diabetes. This type(-8) Don't Know
of diabetes usually develops during childhood or adolescence; but, it also can develop in adults.
(-9) Refused
“Type 2” was formerly called “non-insulin dependent” or “adult-onset” diabetes. Until recently, this type of diabetes
was found only in adults; but, now it is also occurring in children.]
Looking at this card, please tell me which type of diabetes the doctor or other health professional said that [you
have/(SP) has].

OCDTYPE

HFJ41B

code 1

OCDTYPOS

HFJ41B

verbatim text

BOX HFCB

routing

IF (P_OCBETES ^= YES AND (OCBETES = YES or YRBETES = YES)) OR (P_OCBETES = YES AND
P_OCDVISIT ^= YES), GO TO HFJ41C-OCDVISIT.
ELSE GO TO BOX HFJ27.

HFJ41C

yes/no

[Were you/Was (SP)] told on two or more different visits that [you/he/she] had diabetes?

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE AND SP'S AGE AT TIME OF CURRENT MEDICARE ELIGIBILITY
WAS UNDER 65 (sample_person.INTTYPE=3 and AGECALC<65 and greater than 0) THEN
IF SP REPORTED “YES” TO AT LEAST ONE HFJ CONDITION, GO TO HFJ42 - EMCOND.
ELSE IF SP REPORTED “NO” TO ALL HFJ CONDITIONS , GO TO HFJ43 - EMCAUSEVB.
ELSE IF SP IS NOT IN THE SUPPLEMENTAL SAMPLE OR SP'S AGE AT TIME OF CURRENT MEDICARE
ELIGIBILITY WAS NOT UNDER 65 THEN GO TO HFPINTRO - HLTHCAREINTRO.

(01) BOX HFCB
(02) BOX HFCB
(03) BOX HFCB
(04) BOX HFCB
(05) BOX HFCB
(91) HFJ41B - OCDTYPOS
(-8) BOX HFCB
(-9) BOX HFCB

SOME OTHER TYPE (SPECIFY)

OCDVISIT

BOX HFJ27

[IF THE RESPONDENT REPORTS MORE THAN ONE TYPE OF DIABETES, PROBE FOR THE MOST RECENT
TYPE OF DIABETES THE DOCTOR TOLD THE RESPONDENT HE/SHE HAS.]

(01) [Continuous answer.]

BOX HFCB

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

BOX HFJ27

You told me that [you have/(SP) has] had [READ CONDITIONS LISTED BELOW]. [Was this/Were any of these] the
original cause of [your/(SP's)] becoming eligible for Medicare?
(01) YES
(02) NO
(-8) Don't Know
[NOTE THAT CONDITIONS MAY NOT BE DISPLAYED WITH THE EXACT CONDITION NAME THAT WAS USED (-9) Refused
EARLIER IN THE INTERVIEW (E.G., HYPERTENSION CAN ALSO BE CALLED HIGH BLOOD PRESSURE AT
DIFFERENT QUESTIONS).]
[LIST ALL CONDITIONS WHERE "YES" ANSWER RECORDED AT HFJ1 THROUGH HFJ41C]

EMCOND

HFJ42

yes/no

EMCAUSEVB

HFJ43

verbatim text

What was the original cause of [your/(SP's)] becoming eligible for Medicare?
RECORD VERBATIM.

BOX HFJ28

routing

IF SP RESPONDED “YES” TO ONLY ONE HFJ CONDITION, GO TO HFPINTRO - HLTHCAREINTRO.
ELSE GO TO HFJ44 - EMCODE.

(01) [Continuous answer.]

(01) BOX HFJ28
(02) HFJ43 - EMCAUSEVB
(-8) HFPINTRO - HLTHCAREINTRO
(-9) HFPINTRO - HLTHCAREINTRO

HFPINTRO - HLTHCAREINTRO

Page 12 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Which of these conditions was the cause of [your/(SP's)] becoming eligible for Medicare?

Code List

Routing

(01) ARTERIES HARDENING
(02) HYPERTENSION
(03) HEART ATTACK
(04) HEART DISEASE
(05) CONGESTIVE HEART FAILURE
(06) HEART VALVE PROBLEM
(07) HEART RHYTHM PROBLEM
(08) OTHER HEART PROBLEM
(09) STROKE OR HEMORRHAGE
(10) SKIN CANCER
(11) CANCER/TUMOR
(12) RHEUMATOID ARTHRITIS
(26) OSTEOARTHRITIS
(13) OTHER ARTHRITIS
(14) INTELLECTUAL DISABILITY
(15) ALZHEIMER'S
(16) DEMENTIA
(17) DEPRESSION
(18) MENTAL DISORDER
(19) OSTEOPOROSIS
(20) BROKEN HIP
(21) PARKINSON'S
(22) EMPHYSEMA/ASTHMA/COPD
(23) PARALYSIS
(24) LOSS OF LIMB
(25) DIABETES
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) HFPINTRO - HLTHCAREINTRO
(02) HFPINTRO - HLTHCAREINTRO
(03) HFPINTRO - HLTHCAREINTRO
(04) HFPINTRO - HLTHCAREINTRO
(05) HFPINTRO - HLTHCAREINTRO
(06) HFPINTRO - HLTHCAREINTRO
(07) HFPINTRO - HLTHCAREINTRO
(08) HFPINTRO - HLTHCAREINTRO
(09) HFPINTRO - HLTHCAREINTRO
(10) HFPINTRO - HLTHCAREINTRO
(11) HFPINTRO - HLTHCAREINTRO
(12) HFPINTRO - HLTHCAREINTRO
(26) HFPINTRO - HLTHCAREINTRO
(13)HFPINTRO - HLTHCAREINTRO
(14) HFPINTRO - HLTHCAREINTRO
(15) HFPINTRO - HLTHCAREINTRO
(16) HFPINTRO - HLTHCAREINTRO
(17) HFPINTRO - HLTHCAREINTRO
(18) HFPINTRO - HLTHCAREINTRO
(19) HFPINTRO - HLTHCAREINTRO
(20) HFPINTRO - HLTHCAREINTRO
(21) HFPINTRO - HLTHCAREINTRO
(22) HFPINTRO - HLTHCAREINTRO
(23) HFPINTRO - HLTHCAREINTRO
(24) HFPINTRO - HLTHCAREINTRO
(25) HFPINTRO - HLTHCAREINTRO
(91) HFJ44 - EMOS
(-8) HFPINTRO - HLTHCAREINTRO
(-9) HFPINTRO - HLTHCAREINTRO

EMCODE

HFJ44

code all

EMOS

HFJ44

verbatim text

OTHER (SPECIFY)

(01) [Continuous answer.]

HFPINTRO - HLTHCAREINTRO

no entry

Now I want to ask you about some things that [you/(SP)] may be doing to maintain [your/his/her] health, either by
getting tested for health problems or by taking care of conditions that [you have/she has/he has].

(01) CONTINUE
(-7) Empty

BOX HFP1A BOX HFSM1

(01) CONTINUE
(-7) Empty

BOX HFSM2

HLTHCAREINTRO HFPINTRO

[PROBE: Any other condition?]
CHECK UP TO 8 CONDITIONS.

IF (P_OCBETES=YES OR YRBETES=YES) AND (YRHBP^=YES AND YRCHD^=YES AND YRCFAIL^=YES AND
YRSTROKE^=YES AND YRCHOLES^=YES AND YRCANCER^=YES AND P_OCARTHRH^=YES AND
OCARTHRH^=YES AND P_ OCOSARTH^=YES AND OCOSARTH^=YES AND P_OCARTH^=YES AND
YRARTHRD^=YES P_OCALZMER^=YES AND OCALZMER^=YES AND P_OCDEMENT^=YES AND
OCDEMENT^=YES AND YRDEPRSS^=YES AND P_OCOSTEOP^=YES AND OCOSTEOP^=YES AND
P_OCEMPHYS^=YES AND OCEMPHYS^=YES) THEN GO TO BOX HFP1A.
BOX HFSM1

routing

ELSE IF YRHBP=YES OR YRCHD=YES OR YRCFAIL=YES OR YRSTROKE=YES OR YRCHOLES=YES OR
YRCANCER=YES OR P_OCARTHRH= YES OR OCARTHRH=YES OR P_ OCOSARTH= YES OR OCOSARTH
=YES OR P_OCARTH=YES OR YRARTHRD=YES P_OCALZMER=YES OR OCALZMER=YES OR
P_OCDEMENT=YES OR OCDEMENT=YES OR YRDEPRSS=YES OR P_OCOSTEOP=YES OR
OCOSTEOP=YES OR P_OCEMPHYS=YES OR OCEMPHYS=YES OR P_OCBETES=YES OR YRBETES=YES
THEN GO TO SMSINTRO.
ELSE GO TO BOX HFP1A.

SMINTRO

First, I would like to talk to you about [your/(SP's)] chronic conditions. Earlier, you said that [you have/she has/he
has] (CHRONIC CONDITIONS ).

SMINTRO

[IF NEEDED: Right now I am only interested in the conditions I have listed.]

BOX HFSM2

routing

IF R HAS MORE THAN ONE CHRONIC CONDITION, GO TO SMCONCRN. ELSE GO TO SMKNOW.

Page 13 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Which of these conditions concerns [you/(SP)] most?
[DISPLAY CONDITIONS]
SMCONCRN

SMCONCRN

select one
[IF NEEDED: Right now I am only interested in the conditions I have listed.]
[IF NEEDED AND ADMINISTERING TO A PROXY: Please select the condition you think concerns the beneficiary
the most.]

BOX HFSM3

routing

Code List

Routing

(01) ALZHEIMER’S DISEASE
(02) ARTHRITIS, OTHER THAN RHEUMATOID OR (03)
OSTEOARTHRITIS
(04) CANCER, OTHER THAN SKIN CANCER
(05) CONGESTIVE HEART FAILURE
(06) CORONARY HEART DISEASE
(07) DEMENTIA, OTHER THAN ALZHEIMER'S DISEASE
(08) DEPRESSION
(09) DIABETES
(01)- (16) BOX HFSM3
(10) EMPHYSEMA, ASTHMA, OR COPD
(-8) BOX HFP1A
(11) HIGH CHOLESTEROL
(-9) BOX HFP1A
(12) HYPERTENSION
(13) OSTEOARTHRITIS
(14) OSTEOPOROSIS
(15) RHEUMATOID ARTHRITIS
(16) STROKE, BRAIN HEMORRHAGE, OR
CEREBROVASCULAR ACCIDENT
(-8) DON'T KNOW
(-9) REFUSED

IF CONDITION SELECTED AT SMCONCRN=DIABETES THEN GO TO BOX HFP1A
ELSE GO TO SMKNOW.

[Do you/Does (SP)] know of any courses or classes in [your/(SP)'S] community to help people manage
(CONDITION)?
SMKNOW

SMKNOW

yes/no

[IF NEEDED: Examples of courses and classes include exercise classes, workshops and seminars for people with
(CONDITION), or anything else that you think could help with (CONDITION).]

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

SMPRTCPT

[IF NEEDED AND ADMINISTERING TO A PROXY: I am asking about courses or classes the beneficiary may know
of, not classes you may know about.]

[Have you/Has (SP)] ever participated in a course or class on how [you/(SP)] can manage [your/his/her]
(CONDITION)?
SMPRTCPT

SMWHY

SMPRTCPT

SMWHY

yes/no

select all

(01) YES
(02) NO
(-8) DON’T KNOW
[IF NEEDED AND ADMINISTERING TO A PROXY: I am asking about courses or classes the beneficiary may have
(-9) REFUSED
participated in, not classes you may have participated in on behalf of the beneficiary.]

There are many reasons people do not participate in a course or class to help them manage their (CONDITION).
Why [have you/has (SP)] not attended a course or class to help [you/him/her] manage (CONDITION)?
[PROBE: Anything else?]

(01) DID NOT KNOW OF ANY SUCH COURSE/CLASS
(02) DIDN’T SEEM NECESSARY
(03) DIDN’T THINK IT WOULD HELP
(04) TOO EXPENSIVE
(05) INCONVENEINT PLACE
(06) INCONVENIENT TIME
(07) TOO BUSY
(08) TOO MUCH WORK/EFFORT
(09) COURSE/CLASS OF POOR QUALITY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) BOX HFP1A
(02) SMWHY
(-8) BOX HFP1A
(-9) BOX HFP1A

(01)-(09), (-8), (-9) BOX HFP1A
(91) SMWHYOS

Page 14 of 49

2021 MCBS Community Questionnaire

HFQ- Health Status and Functioning

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

SMWHYOS

SMWHYOS

verbatim text

OTHER (SPECIFY)

(01) [Continuous answer.]

BOX HFP1A

BOX HFP1A

routing

IF (P_OCBETES ^= 1/YES) AND (HFJ41A – OCBETES = 1/Yes or YRBETES - YRBETES = 1/YES) AND (HFJ41B
OCDTYPE ^= 5/GESTATIONAL), GO TO HFP1 - DIAAGE.
ELSE IF P_OCBETES = 1/YES, GO TO HFP14A-DIAFEET.
ELSE GO TO BOX HFC2.

HFP1

numeric

(01) [Continuous answer.]
(-7) Empty
(-8) Don't Know
(-9) Refused

BOX HFP2

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

(01) BOX HFC2
(02) HFP4 - DIAINSUL
(-8) BOX HFC2
(-9) BOX HFC2

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

HFP4 - DIAMEDS

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

HFP4 - DIATEST

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

HFP4 - DIASORES

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

HFP4 - DIAPRESS

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

HFP4 - DIAASPRN

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

BOX HFP3

DIAAGE

I recorded that [you were/(SP) was] told by a doctor or other health professional that [you have/she has/he has]
[Type 1 diabetes/Type 2 diabetes/borderline diabetes/pre-diabetes/diabetes].
How old [were you/was (SP)] when [you were/he was/she was] first told that [you/he/she] had diabetes?

BOX HFP2

routing

IF THE SP IS FEMALE (ROSTSEX=2) AND (HFP1 – DIAAGE is >= 12 and is <= 45) OR (HFP1 – DIAAGE = DK
OR RF), GO TO HFP2 - DIAPRGNT.
ELSE GO TO HFP4 - DIAINSUL.

DIAPRGNT

HFP2

yes/no

Did [you/(SP)] have diabetes only during a pregnancy?

DIAINSUL

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take insulin?

DIAMEDS

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take prescription diabetes pills or oral diabetes medicine?

DIATEST

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
test [your/his/her] blood for sugar or glucose?

DIASORES

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
check for sores or irritations on [your/his/her] feet?

DIAPRESS

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
measure [your/his/her] blood pressure at home?

DIAASPRN

HFP4

list

Please tell me whether [you use/(SP) uses] any of the following ways to manage [your/his/her] diabetes. [Do
you/Does (SP)]…
take aspirin regularly for [your/his/her] diabetes?

BOX HFP3

routing

IF HFP4 - DIAINSUL = 1/Yes, GO TO HFP5 - INSUTAKE.
ELSE IF HFP4 - DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.

INSUTAKE

HFP5

quantity unit

How often [do you/does (SP)] take insulin?

(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) USE INSULIN PUMP
(-8) Don't Know
(-9) Refused

(01) HFP5 - INSUDAY
(02) HFP5 - INSUWEEK
(03) BOX HFP4
(-8) BOX HFP4
(-9) BOX HFP4

INSUDAY

HFP5

quantity unit

How often [do you/does (SP)] take insulin?

(01) [Continuous answer.]

BOX HFP4

INSUWEEK

HFP5

quantity unit

How often [do you/does (SP)] take insulin?

(01) [Continuous answer.]

BOX HFP4

routing

IF HFP4 – DIAMEDS = 1/Yes, GO TO HFP6 - MEDSTAKE.
ELSE IF HFP4 - DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 - DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.

BOX HFP4

Page 15 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing
(01) HFP6 - MEDDAY
(02) HFP6 - MEDWEEK
(03) ) HFP6 - MEDMONTH
(-8) BOX HFP5
(-9) BOX HFP5
BOX HFP5

MEDSTAKE

HFP6

quantity unit

How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?

(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(-8) Don't Know
(-9) Refused

MEDDAY

HFP6

quantity unit

How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?

(01) [Continuous answer.]

MEDWEEK

HFP6

quantity unit

How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?

(01) [Continuous answer.]

BOX HFP5

MEDMONTH

HFP6

quantity unit

How often [do you/does (SP)] take prescription diabetes pills or oral diabetes medicine?

(01) [Continuous answer.]

BOX HFP5

BOX HFP5

routing

IF HFP4 – DIATEST = 1/Yes, GO TO HFP7 - TESTTAKE.
ELSE IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.
(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested by (04) NUMBER OF TIMES PER YEAR
a health professional.]
(-8) Don't Know
(-9) Refused
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?

TESTTAKE

HFP7

quantity unit

TESTDAY

HFP7

quantity unit

TESTWEEK

HFP7

quantity unit

TESTMNTH

HFP7

quantity unit

TESTYEAR

HFP7

quantity unit

BOX HFP6

routing

(01) HFP7 - TESTDAY
(02) HFP7 - TESTWEEK
(03) HFP7 - TESTMNTH
(04) HFP7 - TESTYEAR
(-8) BOX HFP6
(-9) BOX HFP6

How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested by
a health professional.]

(01) [Continuous answer.]

BOX HFP6

(01) [Continuous answer.]

BOX HFP6

(01) [Continuous answer.]

BOX HFP6

(01) [Continuous answer.]

BOX HFP6

(01) NUMBER OF TIMES PER DAY
(02) NUMBER OF TIMES PER WEEK
(03) NUMBER OF TIMES PER MONTH
(04) NUMBER OF TIMES PER YEAR
(-8) Don't Know
(-9) Refused

(01) HFP8 - SOREDAY
(02) HFP8 - SOREWEEK
(03) HFP8 - SOREMNTH
(04) HFP8 - SOREYEAR
(-8) HFP10 - DIATENYR
(-9) HFP10 - DIATENYR

(01) [Continuous answer.]

HFP10 - DIATENYR

(01) [Continuous answer.]

HFP10 - DIATENYR

(01) [Continuous answer.]

HFP10 - DIATENYR

How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested by
a health professional.]
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested by
a health professional.]
How often [do you/does (SP)] test [your/his/her] blood for sugar or glucose?
[PROBE: Include times when it is tested by a family member or friend, but do not include times when it is tested by
a health professional.]
IF HFP4 – DIASORES = 1/Yes, GO TO HFP8 - SORECHEK.
ELSE GO TO HFP10 - DIATENYR.

How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
SORECHEK

HFP8

quantity unit

SOREDAY

HFP8

quantity unit

SOREWEEK

HFP8

quantity unit

SOREMNTH

HFP8

quantity unit

[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]

How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]
How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]

Page 16 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

(01) [Continuous answer.]

HFP10 - DIATENYR

How often [do you/does (SP)] check [your/his/her] feet for sores or irritations?
SOREYEAR

HFP8

quantity unit

DIATENYR

HFP10

yes/no

In the past year has a doctor or other health professional examined [your/his/her] feet for sores or irritations?

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

HFP11 - DIADRSAW

DIADRSAW

HFP11

numeric

About how many times in the past year [have you/has (SP)] seen a doctor or other health professional for
[your/his/her] diabetes?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HFP13 - DIAHEMOC

DIAHEMOC

HFP13

numeric

A test of hemoglobin "A one C" measures the average level of blood sugar over the past three months. It is usually (01) [Continuous answer.]
done in a doctor's office. About how many times in the past year has a doctor or other health professional checked (-8) Don't Know
[you/(SP)] for hemoglobin "A one C"?
(-9) Refused

[PROBE: Include times when they are checked by a family member or friend, but do not include times when they
are checked by a health professional.]

SHOW CARD HF6
DIACTRLD

HFP14

code 1

DIAHYPO

HFP14A1

yes/no

Would you say that [your/(SP)'s] blood sugar is well controlled all of the time, most of the time, some of the time, a
little of the time, or none of the time? By "well controlled" we mean a recent hemoglobin "A one C" result of 7.5 or
less or an average fasting blood test of 140 or less.

In the past year, [have you/has (SP)] experienced hypoglycemia, sometimes called low blood sugar or an insulin
reaction?

HFP14 - DIACTRLD

(01) ALL OF THE TIME
(02) MOST OF THE TIME
(03) SOME OF THE TIME
(04) A LITTLE OF THE TIME
(05) NONE OF THE TIME
(-8) Don't Know
(-9) Refused

HFP14A1 - DIAHYPO

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

(01) HFP14A2 - DIAHYPTR
(02) BOX HFCC
(-8) BOX HFCC
(-9) BOX HFCC

(01) SELF TREATMENT
(02) TREATMENT FROM OTHERS
(03) HOSPITAL TREATMENT
(-8) Don't Know
(-9) Refused

BOX HFCC

Please think about the most serious episode of hypoglycemia that [you have/(SP) has] experienced in the past year.

DIAHYPTR

HFP14A2

code 1

[Were you/Was (SP)] able to treat [yourself/himself/herself] by taking some form of sugar, did [you/he/she] require
treatment from others, or did [you/he/she] require treatment by a hospital?
[EXPLAIN IF NECESSARY: Treatment by a hospital includes being treated in the emergency room or outpatient
department of a hospital, or being admitted as an inpatient.]

BOX HFCC

routing

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3) , GO TO HFP14A3-DIAFTEVR.
ELSE GO TO HFP14A-DIAFEET.

DIAFTEVR

HFP14A3

yes/no

[Have you/Has (SP)] ever had any problems with [your/his/her] feet as a result of [your/his/her] diabetes?

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

(01) HFP14A - DIAFEET
(02) HFP15 - DIAEYPRB
(-8) HFP15 - DIAEYPRB
(-9) HFP15 - DIAEYPRB

DIAFEET

HFP14A

yes/no

[Do you/Does (SP)] currently have any problems with [your/his/her] feet as a result of [your/his/her] diabetes?

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

BOX HFCD

BOX HFCD

routing

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIANEURO.
ELSE IF P_DNEURO ^= YES, GO TO YRDNEURO-YRDNEURO.
ELSE GO TO BOX HFCE.

DIANEURO

HFP14B

list

People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as
(01) YES
a result of [your/his/her] diabetes.
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused

BOX HFCE

Neuropathy or nerve damage, which may cause pain or numbness in the feet?

Page 17 of 49

2021 MCBS Community Questionnaire

Variable Name

YRDNEURO

MR Screen Name Question Type

YRDNEURO

yes/no

HFQ- Health Status and Functioning

Question Text/Description

Code List

[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told by a
doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as a
result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused

Routing

BOX HFCE

Neuropathy or nerve damage, which may cause pain or numbness in the feet?

BOX HFCE

DIACIRCF

HFP14B

routing

list

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIACIRCF.
ELSE IF P_DCIRCF ^= YES, GO TO YRDCIRCF-YRDCIRCF.
ELSE GO TO BOX HFCF.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as
(01) YES
a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused

BOX HFCF.

Poor circulation or blood flow in the feet?

YRDCIRCF

YRDCIRCF

yes/no

[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told by a
doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as a
result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused

BOX HFCF

Poor circulation or blood flow in the feet?

BOX HFCF

DIAULCER

HFP14B

routing

list

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIAULCER.
ELSE IF P_DULCER ^= YES, GO TO YRDULCER-YRDULCER.
ELSE GO TO BOX HFCG.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as
(01) YES
a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused

BOX HFCG

Foot ulcers?

YRDULCER

YRDULCER

yes/no

[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told by a
doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as a
result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has (SP)] been told by a doctor or other health
(-8) Don't Know
professional that [you/he/she] had…
(-9) Refused

BOX HFCG

Foot ulcers?

BOX HFCG

DIASKINC

HFP14B

routing

list

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP14B-DIASKINC.
ELSE IF P_DSKINC ^= YES, GO TO YRDSKINC-YRDSKINC.
ELSE GO TO HFP15-DIAEYPRB.
[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] ever been told
by a doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as
(01) YES
a result of [your/his/her] diabetes.]
(02) NO
(-8) Don't Know
[Have you/Has (SP)] ever been told by a doctor or other health professional that [you/he/she] had…
(-9) Refused

HFP15 - DIAEYPRB

Calluses, infections, or other skin changes affecting the feet?

Page 18 of 49

2021 MCBS Community Questionnaire

Variable Name

YRDSKINC

MR Screen Name Question Type

YRDSKINC

yes/no

HFQ- Health Status and Functioning

Question Text/Description

Code List

[People with diabetes can develop many different foot problems. Please tell me if [you have/(SP) has] been told by a
doctor or other health professional that [you/he/she] had any of the following problems with [your/his/her] feet as a
result of [your/his/her] diabetes.]
(01) YES
(02) NO
Since [SAMPLE_PERSON.DATE_FALLRND], [have you/Has SP] been told by a doctor or other health professional (-8) Don't Know
that [you/he/she] had…
(-9) Refused

Routing

HFP15 - DIAEYPRB

Calluses, infections, or other skin changes affecting the feet?

DIAEYPRB

HFP15

yes/no

[Do you/Does (SP)] have any problems with [your/his/her] eyes as a result of [your/his/her] diabetes?

BOX HFCH

routing

IF SP IS IN THE BASELINE INTERIVEW (sample_person.INTTYPE=3), GO TO HFP16A1-DIAKDPEV.
ELSE GO TO HFP16-DIAKDPRB.

HFP16A1

yes/no

[Have you/Has (SP)] ever had any problems with [your/his/her] kidneys as a result of [your/his/her] diabetes?
DIAKDPEV

[EXPLAIN IF NECESSARY: This is tested by looking for protein in the urine.]

DIAKDPRB

HFP16

yes/no

BOX HFC1

routing

[Do you/Does (SP)] currently have any problems with [your/his/her] kidneys as a result of [your/his/her] diabetes?

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

BOX HFCH

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

(01) HFP16 - DIAKDPRB
(02) BOX HFC1
(-8) BOX HFC1
(-9) BOX HFC1

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

(01) BOX HFC1
(02) BOX HFC1
(-8) BOX HFC1
(-9) BOX HFC1

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

DPRTCPT

IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFP17-DIAMNGE.
ELSE GO TO HFP17A-CDIAMNGE.
GO TO DIACLASS.

[Do you/Does (SP)] know of any courses or classes in [your/(SP)'S] community to help people manage diabetes?

DIACLASS

DIACLASS

yes/no

[IF NEEDED: Examples of courses and classes include exercise classes, workshops and seminars for people with
diabetes, or anything else that you think could help with diabetes.]
[IF NEEDED AND ADMINISTERING TO A PROXY: I am asking about courses or classes the beneficiary may know
of, not classes you may know about.]

[Have you/Has (SP)] ever participated in a course or class on how [you/(SP)] can manage [your/his/her] diabetes?
DPRTCPT

DIAWHY

DPRTCPT

DIAWHY

yes/no

select all

(01) YES
(02) NO
[IF NEEDED AND ADMINISTERING TO A PROXY: I am asking about courses or classes the beneficiary may have (-8) DON’T KNOW
(-9) REFUSED
participated in, not classes you may have participated in on behalf of the beneficiary.]

There are many reasons people do not participate in a course or class to help them manage their diabetes. Why
[have you/has (SP)] not attended a course or class to help [you/him/her] manage that condition?
[PROBE: Anything else?]

(01) DID NOT KNOW OF ANY SUCH COURSE/CLASS
(02) DIDN’T SEEM NECESSARY
(03) DIDN’T THINK IT WOULD HELP
(04) TOO EXPENSIVE
(05) INCONVENEINT PLACE
(06) INCONVENIENT TIME
(07) TOO BUSY
(08) TOO MUCH WORK/EFFORT
(09) COURSE/CLASS OF POOR QUALITY
(91) OTHER (SPECIFY)
(-8) DON'T KNOW
(-9) REFUSED

(01) DIARCNT
(02) DIAWHY
(-8) BOX HFP7
(-9) BOX HFP7

BOX HFP7

Page 19 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

When was the most recent time that [you/(SP)] participated in a course or class on how [you/he/she] can manage
[your/his/her] diabetes?
DIARCNT

DIARCNT

code 1

When was the most recent time that you participated in a diabetes self-management course or class or received
special training on how you can manage your diabetes
[IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING, PROBE FOR THE MOST
RECENT TIME.]

Code List

Routing

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

BOX HFP7

DIAMNGE

HFP17

yes/no

[Have you/Has (SP)] ever participated in a diabetes self-management course or class, or received special training
on how [you/he/she] can manage [your/his/her] diabetes?

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

(01) HFP18 - DIATRAIN
(02) BOX HFP7
(-8) BOX HFP7
(-9) BOX HFP7

CDIAMNGE

CDIAMNGE

yes/no

Since [SAMPLE_PERSON.DATE_FALLRND], [have you/has (SP)] participated in a diabetes self-management
course or class, or received special training on how [you/he/she] can manage [your/his/her] diabetes?

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

BOX HFP7

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

BOX HFP7

(01) just about everything you need to know,
(02) most of what you need to know,
(03) some of what you need to know,
(04) a little of what you need to know, or
(05) almost none of what you need to know about
managing your diabetes?
(-8) Don't Know
(-9) Refused

HFP20 - DIASUPPS

When was the most recent time that [you/(SP)] participated in a diabetes self-management course or class or
received special training on how [you/he/she] can manage [your/his/her] diabetes?
DIATRAIN

HFP18

code 1
[IF THE RESPONDENT HAS GONE TO MORE THAN ONE COURSE OR TRAINING, PROBE FOR THE MOST
RECENT TIME.]

BOX HFP7

routing

IF THE SP IS THE RESPONDENT (SPPROXY=1), GO TO HFP19 - DIAKNOW.
ELSE GO TO BOX HFR1.

SHOW CARD HF7
DIAKNOW

HFP19

code 1
How much do you think you know about managing your diabetes? Do you know . . .

DIASUPPS

HFP20

yes/no

(01) YES
Before today, did you know that Medicare now helps pay the cost of diabetic testing supplies and self-management (02) NO
education for people with diabetes?
(-8) Don't Know
(-9) Refused

BOX HFC2

routing

IF SP IS IN THE BASELINE SAMPLE [SAMPLE.PERSON.INTTYPE=3], GO TO HFP21-DIAEVERT.
ELSE GO TO HFP21A-CDIAEVER.

BOX HFR1

Page 20 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[I have recorded that [you have/(SP) has] never been told by a doctor or other health professional that [you have/she
has/he has] diabetes.]

DIAEVERT

HFP21

yes/no

[Have you/Has (SP)] ever had a blood test to see if [you have/she has/he has] diabetes?
[IF NEEDED: This question is asking about whether you have ever had a blood test for diabetes, not whether you
have diabetes.]

Code List

Routing

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

(01) HFP22 - DIARECNT
(02) BOX HFP8
(-8) BOX HFP8
(-9) BOX HFP8

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

(01) HFP24 - DIARISK
(02) BOX HFP8
(-8) BOX HFP8
(-9) BOX HFP8

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

HFP24 - DIARISK

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

HFP24 - DIARISK

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

HFP25 - DIASIGNS

[I have recorded that [you have/(SP) has] never been told by a doctor or other health professional that [you have/she
has/he has] diabetes.]

CDIAEVER

HFP21A

yes/no

Since [SAMPLE_PERSON.DATE_FALLRND, [have you/has (SP)] had a blood test to see if [you have/she has/he
has] diabetes?

[IF NEEDED: This question is asking about whether you have had a blood test since
[SAMPLE_PERSON.DATE_FALLRND for diabetes, not whether you have diabetes.]

DIARECNT

HFP22

code 1

When was the most recent time [you were/(SP) was] tested for diabetes?

BOX HFP8

routing

IF THE SP IS THE RESPONDENT (SPPROXY=1), GO TO HFP23 - DIAAWARE.
ELSE GO TO HFP24 - DIARISK.

DIAAWARE

HFP23

yes/no

Before today, were you aware that there is a blood test to determine if a person has diabetes?

DIARISK

HFP24

yes/no

Has a doctor or other health professional ever told [you/(SP)] that [you are/he is/she is] at high risk for diabetes?
[IF NEEDED: This question is asking about whether you have ever been told you are at risk for diabetes, not
whether you have diabetes.]

In the past year, [have you/has (SP)] received any information about the signs, symptoms, or risk factors for
diabetes?

DIASIGNS

HFP25

yes/no

(01) YES
(02) NO
(-8) Don't Know
[IF NEEDED: This question is asking about whether you have received any information on diabetes, not whether you
(-9) Refused
have diabetes.]

BOX HFR1

routing

IF (SP HAS EVER HEARD ABOUT COLORECTAL OR COLON CANCER IS UNKNOWN P_COLHEAR=.) AND
(SP HAS NOT REPORTED HAVING COLON, RECTAL OR BOWEL CANCER IN THE CURRENT ROUND OR IN
A PREVIOUS ROUND (OCCCODE not in 02 and P_OCCCOLON^=1), GO TO HFR1 - COLHEAR.
ELSE GO TO BOX HFS1.

HFR1

yes/no

Now I'd like to talk about a different illness, colorectal or colon cancer, a disease of the lower intestines.
COLHEAR

Before today, had [you/SP] ever heard of colorectal or colon cancer?

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

BOX HFR1

BOX HFC3

Page 21 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

BOX HFC3

routing

IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFR3 - COLHTEST.
ELSE GO TO HFR3A - CCOLHTES.

HFR3

yes/no

The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible traces of blood found in
(01) YES
the stool. The doctor or other health professional can give the patient a kit to collect stool samples at the patient’s
(02) NO
home. The test is then sent to a laboratory for the results to be determined.
(-8) Don't Know
(-9) Refused
Has a doctor or other health professional ever given [you/(SP)] a home testing kit to test for blood in the stool?

(01) HFR5 - COLCARD
(02) BOX HFC4
(-8) BOX HFC4
(-9) BOX HFC4

HFR3A

yes/no

The fecal occult blood test is a simple test for early signs of colon cancer. It detects invisible traces of blood found in
the stool. The doctor or other health professional can give the patient a kit to collect stool samples at the patient’s
(01) YES
home. The test is then sent to a laboratory for the results to be determined.
(02) NO
(-8) Don't Know
Since (SAMPLE_PERSON.DATE_FALLRND), Has a doctor or other health professional given [you/(SP)] a home
(-9) Refused
testing kit to test for blood in the stool?

(01) HFR5 - COLCARD
(02) BOX HFC4
(-8) BOX HFC4
(-9) BOX HFC4

BOX HFC4

routing

IF P_COLHKIT=YES, GO TO HFR4A - COLFDOC.
ELSE GO TO HFR4-COLHKIT.

COLHKIT

HFR4

yes/no

[Have you/Has SP] ever heard of this home testing kit?

COLFDOC

HFR4A

yes/no

(01) YES
Has a doctor or other health professional ever performed a fecal occult blood test to test for blood in the stool while (02) NO
[you/(SP)] [were/was] at the doctor’s office?
(-8) Don't Know
(-9) Refused

COLCARD

HFR5

yes/no

BOX HFC5

routing

COLHTEST

CCOLHTES

Did [you/(SP)] complete the samples and return them for [your/his/her] most recent test?
[READ IF NECESSARY: The fecal occult blood test is a simple test for early signs of colon cancer. It detects
invisible traces of blood found in the stool.]

HFR7

code 1
[READ IF NECESSARY: The fecal occult blood test is a simple test for early signs of colon cancer. It detects
invisible traces of blood found in the stool.]

BOX HFC6

COLORECT

COLORECT

routing

yes/no

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

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

Routing

HFR4A - COLFDOC

(01) HFR7 - COLRECNT
(02) BOX HFC6
(-8) BOX HFC6
(-9) BOX HFC6

BOX HFC5

IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFR7 - COLRECNT.
ELSE GO TO BOX HFC6.

When did [you/(SP)] have [your/his/her] most recent blood stool test [(using a home testing kit)/(at the doctor's
office)]?
COLRECNT

Code List

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

BOX HFC6

IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO]COLORECT-COLORECT.
ELSE GO TO CCOLOREC-CCOLOREC.
These next questions are about colorectal cancer screening. There are several different kinds of tests to check for
colon cancer.
Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube
into the rectum to look for polyps or cancer.
[Have you/Has (SP)] ever had either of these exams?

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

(01) CORECTYP
(02) BOX HFC7
(-8) BOX HFC7
(-9) BOX HFC7

Page 22 of 49

2021 MCBS Community Questionnaire

Variable Name

CORECTYP

CCOLOREC

MR Screen Name Question Type

CORECTYP

CCOLOREC

code 1

yes/no

HFQ- Health Status and Functioning

Question Text/Description

These next questions are about colorectal cancer screening. There are several different kinds of tests to check for
colon cancer.
Colonoscopy (colon-OS-copy) and sigmoidoscopy (sigmoid-OS-copy) are exams in which a doctor inserts a tube
into the rectum to look for polyps or cancer.
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had either of these exams?

CCORECTP

CCORECTP

code 1

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

For a colonoscopy, the doctor checks the entire colon, and you are given medication through a
needle in your arm to make you sleepy, and told to have someone take you home. For a sigmoidoscopy, the doctor (01) Colonoscopy
checks only part of the colon and you are fully awake.
(02) Sigmoidoscopy
(03) Both
(-8) Don't Know
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had a colonoscopy, a sigmoidoscopy, or both? (-9) Refused

When did [you/(SP)] have [your/his/her] most recent sigmoidoscopy or colonoscopy?
WHENSCOP

Code List

For a colonoscopy, the doctor checks the entire colon, and you are given medication through a
needle in your arm to make you sleepy, and told to have someone take you home. For a sigmoidoscopy, the doctor (01) Colonoscopy
checks only part of the colon and you are fully awake.
(02) Sigmoidoscopy
(03) Both
(-8) Don't Know
[Have you/Has (SP)] ever had a colonoscopy, a sigmoidoscopy, or both?
(-9) Refused

Routing

(01) HFR9 - WHENSCOP
(02) HFR9 - WHENSCOP
(03) HFR9 - WHENSCOP
(-8) BOX HFC7
(-9) BOX HFC7

(01) CCORECTP
(02) BOX HFC7
(-8) BOX HFC7
(-9) BOX HFC7

BOX HFC7

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

HFR13 - COLSCRNS

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

(01) HFR11 - COLDRREC
(02) BOX HFR2
(-8) BOX HFR2
(-9) BOX HFR2

HFR9

code 1

BOX HFC7

routing

IF P_HEARSCOP=YES OR CCOLOREC=YES, GO TO BOX HFR2.
ELSE GO TO HFR10- HEARSIG.

HFR10

yes/no

Before today, had [you/(SP}] ever heard of a sigmoidoscopy or colonoscopy?

BOX HFR2

routing

IF HFR3 - COLHTEST = 1/Yes or HFR4 - COLHKIT = 1/Yes, GO TO HFR13 - COLSCRNS.
ELSE GO TO BOX HFS1.

COLDRREC

HFR11

yes/no

Has a doctor or other health professional ever recommended that [you/(SP)] have this test?

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

HFR13 - COLSCRNS

COLSCRNS

HFR13

yes/no

Before today, did [you/(SP)] know that Medicare now pays the cost of screening tests for colorectal cancer?

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

BOX HFS1

BOX HFS1

routing

IF SP HAS EVER REPORTED HAVING OSTEPOPORIS IN THE CURRENT ROUND OR IN A PREVIOUS ROUND
(OCOSTEOP=1 or sample_person.P_OCOSTEOP-=1 GO TO BOX HFC8.
ELSE GO TO HFSINTRO - OSTINTRO.

HFSINTRO

no entry

Now I'd like to talk about a disease called osteoporosis, which can be treated if found early. In osteoporosis, the
bones lose their calcium and become fragile and more easily broken.

(01) CONTINUE
(-7) Empty

HFS1 - OSTEVERT

HEARSIG

OSTINTRO

[IF NEEDED: If you had both exams done, then please provide the date for the most recent exam]

Page 23 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing
(01) HFS2 - OSTHRISK
(02) BOX HFC8
(-8) BOX HFC8
(-9) BOX HFC8

HFS2A - OSTFRACT

OSTEVERT

HFS1

yes/no

[Have you/Has (SP)] ever talked with [your/his/her] doctor or other health professional about osteoporosis?

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

OSTHRISK

HFS2

yes/no

Has a doctor or other health professional ever told [you/(SP)] that [you are/he is/she is] at high risk for osteoporosis?

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

OSTFRACT

HFS2A

yes/no

(01) YES
Have [you/(SP)] ever experienced a fracture that [your/his/her] doctor or other health professional told [you/him/her] (02) NO
was related to osteoporosis?
(-8) Don't Know
(-9) Refused

BOX HFC8

routing

IF SP IS IN THE BASELINE SAMPLE [sample_person.INTTYPE=3], GO TO HFS3-OSTTEST.
ELSE GO TO HFS3A-COSTTEST.

HFS3

yes/no

OSTTEST

There is a test to detect osteoporosis at an early stage, called Bone Mass Measurement or Bone Density
Measurement, or DEXA scan.
[Have you/Has (SP)] ever had a Bone Mass or Bone Density Measurement test?

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

There is a test to detect osteoporosis at an early stage, called Bone Mass Measurement or Bone Density
Measurement, or DEXA scan.

COSTTEST

OSTHEAR

BOX HFC8

(01) HFS5 - OSTRECNT
(02) BOX HFC9
(-8) BOX HFC9
(-9) BOX HFC9

HFS3A

yes/no

(01) YES
(02) NO
(-8) Don't Know
Since (SAMPLE_PERSON.DATE_FALLRND), [have you/has (SP)] had a Bone Mass or Bone Density Measurement
(-9) Refused
test?

BOX HFC9

routing

IF P_OSTHEAR=YES, GO TO HFS6 - OSTMASS.
ELSE GO TO HFS4-OSTHEAR.

HFS4

yes/no

Before today, had you ever heard of this test?

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

(01) HFS6 - OSTMASS
(02) HFAC29 - HCTROUBL
(-8) HFAC29 - HCTROUBL
(-9) HFAC29 - HCTROUBL

HFS6 - OSTMASS

HFAC29 - HCTROUBL

OSTRECNT

HFS5

code 1

When was the most recent time that [you/(SP)] had a Bone Mass or Bone Density Measurement test?

(01) LESS THAN 1 YEAR AGO
(02) 1 YEAR TO LESS THAN 2 YEARS
(03) 2 YEARS TO LESS THAN 3 YEARS
(04) 3 YEARS TO LESS THAN 4 YEARS
(05) 4 YEARS TO LESS THAN 5 YEARS
(06) 5 YEARS TO LESS THAN 6 YEARS
(07) 6 YEARS TO LESS THAN 7 YEARS
(08) 7 YEARS TO LESS THAN 8 YEARS
(09) 8 YEARS TO LESS THAN 9 YEARS
(10) 9 YEARS TO LESS THAN 10 YEARS
(11) 10 YEARS AGO OR MORE
(12) 5 YEARS AGO OR MORE
(996) NEVER HAD EXAM
(-8) DON'T KNOW
(-9) REFUSED

OSTMASS

HFS6

yes/no

Before today, did you know that Medicare would pay for Bone Mass or Bone Density Measurement tests for
Medicare beneficiaries who are at risk for osteoporosis?

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

HCTROUBL

HFAC29

yes/no

Next, we are going to ask some questions about [your/(SP's)] health care needs during the past year.

(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] had any trouble getting health care that [you/he/she] wanted (-8) Don't Know
or needed?
(-9) Refused

(01) HFS6 - OSTMASS
(02) BOX HFC9
(-8) BOX HFC9
(-9) BOX HFC9

(01) HFAC30A - HCTCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY

Page 24 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Why was that?
HCTCODE

HFAC30A

code all

HCTOTHOS

HFAC30A

verbatim text

OTHER (SPECIFY)

BOX HFF6

routing

IF RESPONSE TO HFAC30A - HCTCODE INCLUDES 8/DrDoesNotAcceptMedicare OR 10/DifficultyGettingAppt,
GO TO HFAC30D - OFFEXPLN.
ELSE GO TO HFAC30B - CGETAPPT.

HFAC30B

yes/no

Since (LAST HF MONTH YEAR), [have you/has (SP)] been told by a doctor’s office that they cannot schedule an
appointment with [you/(SP)]?

CGETAPPT

[PROBE: Any other reason?]
CHECK ALL THAT APPLY.

What were the reasons the doctor’s office offered as an explanation for not scheduling an appointment with
[you/(SP)]?
CGETCODE

HFAC30C

code all
[PROBE: Any other reason?]
CHECK ALL THAT APPLY

CGETOTOS

Code List

Routing

(01) SP DOES NOT HAVE MONEY
(02) COST IS TOO HIGH
(03) SERVICES/SUPPLIES NOT COVERED
(04) NEEDED TRANSPORTATION TO
DOCTOR/HOSPITAL
(05) DIFFICULTY GETTING HOME HEALTH CARE
(06) NO TREATMENT AVAILABLE/DOCTOR WON’T
TREAT
(07) WAIT TOO LONG/DOCTOR TOO BUSY
(08) OWN DOCTOR DOESN’T ACCEPT
MEDICARE/COULDN’T FIND DOCTOR WHO
ACCEPTS MEDICARE
(09) NOT ELIGIBLE FOR PUBLIC COVERAGE
(10) DIFFICULTY GETTING APPOINTMENT/ DELAYS
BECAUSE SP ON MEDICARE
(11) DOCTOR REFERRED SP TO SPECIALIST OR
OTHER DOCTOR
(12) HMO REFERRAL PROCESS (DIFFICULTY
GETTING)
(13) PROBLEMS WITH HMO DOCTORS NOT GOOD
OR AVAILABLE
(14) HMO WOULD NOT COVER OR PROVIDE
SERVICE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX HFF6
(02) BOX HFF6
(03) BOX HFF6
(04) BOX HFF6
(05) BOX HFF6
(06) BOX HFF6
(07) BOX HFF6
(08) BOX HFF6
(09) BOX HFF6
(10) BOX HFF6
(11) BOX HFF6
(12) BOX HFF6
(13) BOX HFF6
(14) BOX HFF6
(91) HFAC30A - HCTOTHOS
(-8) BOX HFF6
(-9) BOX HFF6

(01) [Continuous answer.]

BOX HFF6

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

(01) HFAC30C - CGETCODE
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY

(01) DOCTOR DOES NOT ACCEPT INSURANCE PLAN
(02) ALL OF DOCTORS APPOINTMENTS WERE FULL
(03) DOCTOR IS NOT ACCEPTING ANY NEW
PATIENTS
(04) DOCTOR IS NOT ACCEPTING NEW MEDICARE
PATIENTS
(05) DOCTORS HOURS CONFLICTED WITH
REQUIREMENTS OF SP
(06) DOCTOR DOES NOT ACCEPT MEDICAID
(07) DOCTOR DOES NOT ACCEPT MEDICARE AT ALL
(08) DOCTOR DOES NOT ACCEPT MEDICARE
ASSIGNMENT
(09) DOCTOR FELT ANOTHER PROVIDER WOULD BE
BETTER FOR SP
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) BOX HFF7
(02) BOX HFF7
(03) BOX HFF7
(04) BOX HFF7
(05) BOX HFF7
(06) BOX HFF7
(07) BOX HFF7
(08) BOX HFF7
(09) BOX HFF7
(91) HFAC30C - CGETOTOS
(-8) BOX HFF7
(-9) BOX HFF7

(01) [Continuous answer.]

BOX HFF7

CGETOTOS

verbatim text

Please specify the other reason.

BOX HFF7

routing

IF RESPONSE TO HFAC30C - CGETCODE INCLUDES 4/DocNotAcceptNewMedicare OR
7/DocNotAcceptMCAR, GO TO HFAC30D - OFFEXPLN.
ELSE GO TO HFAC31 - HCDELAY.

OFFEXPLN

HFAC30D

yes/no

Did the doctor’s office explain why [it is difficult for Medicare patients to get an appointment/Medicare is not
accepted] at that practice?

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

(01) HFAC30E - OFFEXVB
(02) HFAC31 - HCDELAY
(-8) HFAC31 - HCDELAY
(-9) HFAC31 - HCDELAY

OFFEXVB

HFAC30E

verbatim text

What was that explanation?
RECORD VERBATIM.

(01) [Continuous answer.]

HFAC31 - HCDELAY

Page 25 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

HCDELAY

HFAC31

yes/no

(01) YES
Since (LAST HF MONTH YEAR), [have you/has (SP)] delayed seeking medical care because (you were/he was/she (02) NO
was) worried about the cost?
(-8) Don't Know
(-9) Refused

PAYPROB

HFAC32A

yes/no

Since (LAST HF MONTH YEAR) [have you/has (SP)] had problems paying or were unable to pay any medical bills?

COLLAGNCY

HFAC32

yes/no

(01) YES
Because of problems paying medical bills since (LAST HF MONTH YEAR), [have you/has (SP)] been contacted by (02) NO
a collection agency?
(-8) Don't Know
(-9) Refused

PAYOVRTM

HFAC32B

yes/no

[Do you /Does (SP)] currently have any medical bills that are being paid off over time?

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

HFKINTRO - IADLINTRO

IADLINTRO

HFKINTRO

no entry

Health problems can include physical, mental, emotional, or memory problems. I'd now like to ask you about how
health problems may affect [your/(SP)'s] ability to perform some other everyday activities. I’d like to know whether
[you have/(SP) has] any difficulty doing each activity by [yourself/himself/herself].

(01) CONTINUE
(-7) Empty

HFKA1 - PRBTELE

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFKB1 - PRBLHWK
(02) HFKB1 - PRBLHWK
(03) HFKA2 - DONTTELE
(-8) HFKB1 - PRBLHWK
(-9) HFKB1 - PRBLHWK

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

HFKB1 - PRBLHWK

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFKC1 - PRBHHWK
(02) HFKC1 - PRBHHWK
(03) HFKB2 - DONTLHWK
(-8) HFKC1 - PRBHHWK
(-9) HFKC1 - PRBHHWK

Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty...
PRBTELE

HFKA1

code 1
using the telephone?

[You said that using the telephone is something that [you don't/(SP) doesn't] do.]
DONTTELE

HFKA2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBLHWK

HFKB1

code 1
doing light housework (like washing dishes, straightening up, or light cleaning)?

DONTLHWK

HFKB2

yes/no

HFKC1

code 1
doing heavy housework (like scrubbing floors or washing windows)?

DONTHHWK

HFKC2

yes/no

HFKD1

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

[You said that doing heavy housework (like scrubbing floors or washing windows) is something that [you don't/(SP) (01) YES
doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a physical, mental, emotional, or memory problem?
(-9) Refused

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBMEAL

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

[You said that doing light housework (like washing dishes, straightening up, or light cleaning) is something that [you (01) YES
don't/(SP) doesn't] do.]
(02) NO
(-8) Don't Know
Is this because of a physical, mental, emotional, or memory problem?
(-9) Refused

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBHHWK

Code List

code 1
preparing [your/his/her] own meals?

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

Routing

HFAC32 A-PAYPROB

(01) HFAC32 - COLLAGNCY
(02) HFKINTRO - IADLINTRO
(-8) HFKINTRO - IADLINTRO
(-9) HFKINTRO - IADLINTRO

HFAC32B- PAYOVRTM

HFKC1 - PRBHHWK

(01) HFKD1 - PRBMEAL
(02) HFKD1 - PRBMEAL
(03) HFKC2 - DONTHHWK
(-8) HFKD1 - PRBMEAL
(-9) HFKD1 - PRBMEAL

HFKD1 - PRBMEAL

(01) HFKE1 - PRBSHOP
(02) HFKE1 - PRBSHOP
(03) HFKD2 - DONTMEAL
(-8) HFKE1 - PRBSHOP
(-9) HFKE1 - PRBSHOP

Page 26 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[You said that preparing [your/his/her] own meals is something that [you don't/(SP) doesn't] do.]

DONTMEAL

HFKD2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBSHOP

HFKE1

code 1
shopping for personal items (such as toilet items or medicines)?

DONTSHOP

HFKE2

yes/no

[You said that shopping for personal items (such as toilet items or medicines) is something that [you don't/(SP)
doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
PRBBILS

HFKF1

code 1
managing money (like keeping track of expenses or paying bills)?

DONTBILS

HFKF2

yes/no

[You said that managing money (like keeping track of expenses or paying bills) is something that [you don't/(SP)
doesn't] do.]
Is this because of a physical, mental, emotional, or memory problem?

BOX HFKA1

routing

HFKA3

yes/no

Routing

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

HFKE1 - PRBSHOP

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFKF1 - PRBBILS
(02) HFKF1 - PRBBILS
(03) HFKE2 - DONTSHOP
(-8) HFKF1 - PRBBILS
(-9) HFKF1 - PRBBILS

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

HFKF1 - PRBBILS

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) BOX HFKA1
(02) BOX HFKA1
(03) HFKF2 - DONTBILS
(-8) BOX HFKA1
(-9) BOX HFKA1

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

BOX HFKA1

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

(01) HFKA4 - PERSON_HLPRTELE
(02) BOX HFKB1
(-8) BOX HFKB1
(-9) BOX HFKB1

IF HFKA1 - PRBTELE = 1/Yes OR HFKA2 – DONTTELE = 1/Yes, GO TO HFKA3 - HELPTELE.
ELSE GO TO BOX HFKB1.
[[You said that [your/(SP's)] health makes using the telephone difficult./You said that using the telephone is
something that [you don't do/(SP) doesn't do].]]

HELPTELE

Code List

[Do you/Does (SP)] receive help from another person with...
using the telephone?

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRT
HFKA4
ELE

roster

You mentioned that [you receive/(SP) receives] help with using the telephone. Who gives that help?
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRTELE = (N+1), GO TO HFKA4_NEWROSTFNAM,
ELSE GO TO BOX HFKB1

ROSTFNAM

HFKA4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKA4_NEW - ROSTLNAM

ROSTLNAM

HFKA4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKA4_NEW - ROSTREL

Page 27 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFKA4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKA4_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFKB1

routing

IF HFKB1 - PRBLHWK = 1/Yes or HFKB2 - DONTLHWK = 1/Yes, GO TO HFKB3 - HELPLHWK.
ELSE GO TO BOX HFKC1.
[[You said that [your/(SP's)] health makes doing light housework (like washing dishes, straightening up, or light
cleaning) difficult./You said that doing light housework (like washing dishes, straightening up, or light cleaning) is
something that [you don't do/(SP) doesn't do].]]

HELPLHWK

HFKB3

yes/no
[Do you/Does (SP)] receive help from another person with...

Code List

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

Routing
(01) DO NOT DISPLAY
(02) BOX HFKB1
(03) BOX HFKB1
(04) BOX HFKB1
(05) BOX HFKB1
(06) BOX HFKB1
(07) BOX HFKB1
(08) BOX HFKB1
(09) BOX HFKB1
(10) BOX HFKB1
(11) BOX HFKB1
(12) BOX HFKB1
(13) BOX HFKB1
(14) BOX HFKB1
(50) DO NOT DISPLAY
(51) BOX HFKB1
(52) BOX HFKB1
(53) BOX HFKB1
(54) BOX HFKB1
(55) BOX HFKB1
(56) BOX HFKB1
(57) BOX HFKB1
(91) HFKA4_NEW - ROSTREOS
(-8) BOX HFKB1
(-9) BOX HFKB1

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFKB1

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

(01) HFKB4 - PERSON_HLPRLHWK
(02) BOX HFKC1
(-8) BOX HFKC1
(-9) BOX HFKC1

doing light housework (like washing dishes, straightening up, or light cleaning)?
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
You mentioned that [you receive/(SP) receives] help with doing light housework (like washing dishes, straightening
DISPLAY:
up, or light cleaning). Who gives that help?
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRLHWK = (N+1), GO TO HFKB4_NEWROSTFNAM,
ELSE GO TO BOX HFKC1

PERSON_HLPRL
HFKB4
HWK

roster

ROSTFNAM

HFKB4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKB4_NEW - ROSTLNAM

ROSTLNAM

HFKB4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKB4_NEW - ROSTREL

Page 28 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFKB4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKB4_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFKC1

routing

IF HFKC1 - PRBHHWK = 1/Yes or HFKC2 - DONTHHWK = 1/Yes, GO TO HFKC3 - HELPHHWK.
ELSE GO TO BOX HFKD1
[[You said that [your/(SP's)] health makes doing heavy housework (like scrubbing floors or washing windows)
difficult./You said that heavy housework (like scrubbing floors or washing windows) is something that [you don't
do/(SP) doesn't do].]]

HELPHHWK

HFKC3

yes/no
[Do you/Does (SP)] receive help from another person with...

Code List

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

Routing
(01) DO NOT DISPLAY
(02) BOX HFKC1
(03) BOX HFKC1
(04) BOX HFKC1
(05) BOX HFKC1
(06) BOX HFKC1
(07) BOX HFKC1
(08) BOX HFKC1
(09) BOX HFKC1
(10) BOX HFKC1
(11) BOX HFKC1
(12) BOX HFKC1
(13) BOX HFKC1
(14) BOX HFKC1
(50) DO NOT DISPLAY
(51) BOX HFKC1
(52) BOX HFKC1
(53) BOX HFKC1
(54) BOX HFKC1
(55) BOX HFKC1
(56) BOX HFKC1
(57) BOX HFKC1
(91) HFKB4_NEW - ROSTREOS
(-8) BOX HFKC1
(-9) BOX HFKC1

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFKC1

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

(01) HFKC4 - PERSON_HLPRHHWK
(02) BOX HFKD1
(-8) BOX HFKD1
(-9) BOX HFKD1

doing heavy housework (like scrubbing floors or washing windows)?
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRH
HFKC4
HWK

roster

You mentioned that [you receive/(SP) receives] help with doing heavy housework (like scrubbing floors or washing
windows). Who gives that help?
ENTER ALL HELPERS.

ROSTFNAM

HFKC4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKC4_NEW - ROSTLNAM

ROSTLNAM

HFKC4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKC4_NEW - ROSTREL

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRHHWK = (N+1), GO TO HFKC4_NEWROSTFNAM.
ELSE GO TO BOX HFKD1.

Page 29 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFKC4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKC4_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFKD1

routing

IF HFKD1 – PRBMEAL = 1/Yes or HFKD2 – DONTMEAL = 1/Yes, GO TO HFKD3 - HELPMEAL.
ELSE GO TO BOX HFKE1.
[[You said that [your/(SP's)] health makes preparing [your/his/her] own meals difficult./You said that preparing
[your/his/her] own meals is something that [you don't do/(SP) doesn't do].]]

HELPMEAL

HFKD3

yes/no

[Do you/Does (SP)] receive help from another person with...

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFKD1
(03) BOX HFKD1
(04) BOX HFKD1
(05) BOX HFKD1
(06) BOX HFKD1
(07) BOX HFKD1
(08) BOX HFKD1
(09) BOX HFKD1
(10) BOX HFKD1
(11) BOX HFKD1
(12) BOX HFKD1
(13) BOX HFKD1
(14) BOX HFKD1
(50) DO NOT DISPLAY
(51) BOX HFKD1
(52) BOX HFKD1
(53) BOX HFKD1
(54) BOX HFKD1
(55) BOX HFKD1
(56) BOX HFKD1
(57) BOX HFKD1
(91) HFKC4_NEW - ROSTREOS
(-8) BOX HFKD1
(-9) BOX HFKD1

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFKD1

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

(01) HFKD4 - PERSON_HLPRMEAL
(02) BOX HFKE1
(-8) BOX HFKE1
(-9) BOX HFKE1

preparing [your/his/her] own meals?
DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
You mentioned that [you receive/(SP) receives] help with preparing [your/his/her] own meals. Who gives that help?
DISPLAY:
ENTER ALL HELPERS.
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRMEAL = (N+1), GO TO HFKD4_NEWROSTFNAM.
ELSE GO TO BOX HFKE1.

PERSON_HLPRM
HFKD4
EAL

roster

ROSTFNAM

HFKD4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKD4_NEW - ROSTLNAM

ROSTLNAM

HFKD4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKD4_NEW - ROSTREL

Page 30 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFKD4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKD4_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFKE1

routing

IF HFKE1 – PRBSHOP = 1/Yes or HFKE2 – DONTSHOP = 1/Yes, GO TO HFKE3 - HELPSHOP.
ELSE GO TO BOX HFKF1.
[[You said that [your/(SP's)] health makes shopping for personal items (such as toilet items or medicines)
difficult./You said that shopping for personal items (such as toilet items or medicines) is something that [you don't
do/(SP) doesn't do].]]

HELPSHOP

HFKE3

yes/no
[Do you/Does (SP)] receive help from another person with...

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFKE1
(03) BOX HFKE1
(04) BOX HFKE1
(05) BOX HFKE1
(06) BOX HFKE1
(07) BOX HFKE1
(08) BOX HFKE1
(09) BOX HFKE1
(10) BOX HFKE1
(11) BOX HFKE1
(12) BOX HFKE1
(13) BOX HFKE1
(14) BOX HFKE1
(50) DO NOT DISPLAY
(51) BOX HFKE1
(52) BOX HFKE1
(53) BOX HFKE1
(54) BOX HFKE1
(55) BOX HFKE1
(56) BOX HFKE1
(57) BOX HFKE1
(91) HFKD4_NEW - ROSTREOS
(-8) BOX HFKE1
(-9) BOX HFKE1

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFKE1

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

(01) HFKE4 - PERSON_HLPRSHOP
(02) BOX HFKF1
(-8) BOX HFKF1
(-9) BOX HFKF1

shopping for personal items (such as toilet items or medicines)?

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRS
HFKE4
HOP

roster

You mentioned that [you receive/(SP) receives] help with shopping for personal items (such as toilet items or
medicines). Who gives that help?
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRSHOP = (N+1), GO TO HFKE4_NEWROSTFNAM.
ELSE GO TO BOX HFKF1.

ROSTFNAM

HFKE4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKE4_NEW - ROSTLNAM

ROSTLNAM

HFKE4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKE4_NEW - ROSTREL

Page 31 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFKE4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKE4_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFKF1

routing

IF HFKF1- PRBBILS = 1/Yes or HFKF2 – DONTBILS = 1/Yes, GO TO HFKF3 - HELPBILS.
ELSE GO TO HFLINTRO - ADLSINTRO.

HELPBILS

HFKF3

yes/no

Code List

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

[[You said that [your/(SP's)] health makes managing money (like keeping track of expenses or paying bills)
difficult./You said that managing money (like keeping track of expenses or paying bills) is something that [you don't
(01) YES
do/(SP) doesn't do].]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with...
(-9) Refused

Routing
(01) DO NOT DISPLAY
(02) BOX HFKF1
(03) BOX HFKF1
(04) BOX HFKF1
(05) BOX HFKF1
(06) BOX HFKF1
(07) BOX HFKF1
(08) BOX HFKF1
(09) BOX HFKF1
(10) BOX HFKF1
(11) BOX HFKF1
(12) BOX HFKF1
(13) BOX HFKF1
(14) BOX HFKF1
(50) DO NOT DISPLAY
(51) BOX HFKF1
(52) BOX HFKF1
(53) BOX HFKF1
(54) BOX HFKF1
(55) BOX HFKF1
(56) BOX HFKF1
(57) BOX HFKF1
(91) HFKE4_NEW - ROSTREOS
(-8) BOX HFKF1
(-9) BOX HFKF1

BOX HFKF1

(01) HFKF4 - PERSON_HLPRBILS
(02) HFLINTRO - ADLSINTRO
(-8) HFLINTRO - ADLSINTRO
(-9) HFLINTRO - ADLSINTRO

managing money (like keeping track of expenses or paying bills)?

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRBI
HFKF4
LS

roster

You mentioned that [you receive/(SP) receives] help with managing money (like keeping track of expenses or paying
bills). Who gives that help?
DISPLAY:
ENTER ALL HELPERS.
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRBILS = (N+1), GO TO HFKF4_NEWROSTFNAM.
ELSE GO TO HFLINTRO - ADLSINTRO.

ROSTFNAM

HFKF4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKF4_NEW - ROSTLNAM

ROSTLNAM

HFKF4_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFKF4_NEW - ROSTREL

Page 32 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

ROSTREL

HFKF4_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFKF4_NEW

text

[What is the name of the person and relationship to (SP)?]

ADLSINTRO

HFLINTRO

no entry

Remembering that health problems can include physical, mental, emotional, or memory problems, I'd now like to
ask you about how health problems may affect [your/(SP)'s] ability to perform some other everyday activities. I’d like (01) CONTINUE
to know whether [you have/(SP) has] any difficulty doing each activity by [yourself/himself/herself] and without
(-7) Empty
special equipment.

Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty...
HPPDBATH

HFLA1

code 1
bathing or showering?

[You said that bathing or showering is something that [you don't/(SP) doesn't] do.]
DONTBATH

HFLA2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDDRES

HFLB1

code 1
dressing?

[You said that dressing is something that [you don't/(SP) doesn't] do.]
DONTDRES

HFLB2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDEAT

HFLC1

code 1
eating?

[You said that eating is something that [you don't/(SP) doesn't] do.]
DONTEAT

HFLC2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

Routing
(01) DO NOT DISPLAY
(02) HFLINTRO - ADLSINTRO
(03) HFLINTRO - ADLSINTRO
(04) HFLINTRO - ADLSINTRO
(05) HFLINTRO - ADLSINTRO
(06) HFLINTRO - ADLSINTRO
(07) HFLINTRO - ADLSINTRO
(08) HFLINTRO - ADLSINTRO
(09) HFLINTRO - ADLSINTRO
(10) HFLINTRO - ADLSINTRO
(11) HFLINTRO - ADLSINTRO
(12) HFLINTRO - ADLSINTRO
(13) HFLINTRO - ADLSINTRO
(14) HFLINTRO - ADLSINTRO
(50) DO NOT DISPLAY
(51) HFLINTRO - ADLSINTRO
(52) HFLINTRO - ADLSINTRO
(53) HFLINTRO - ADLSINTRO
(54) HFLINTRO - ADLSINTRO
(55) HFLINTRO - ADLSINTRO
(56) HFLINTRO - ADLSINTRO
(57) HFLINTRO - ADLSINTRO
(91) HFKF4_NEW - ROSTREOS
(-8) HFLINTRO - ADLSINTRO
(-9) HFLINTRO - ADLSINTRO

HFLINTRO - ADLSINTRO

HFLA1 - HPPDBATH

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFLB1 - HPPDDRES
(02) HFLB1 - HPPDDRES
(03) HFLA2 - DONTBATH
(-8) HFLB1 - HPPDDRES
(-9) HFLB1 - HPPDDRES

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

HFLB1 - HPPDDRES

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFLC1 - HPPDEAT
(02) HFLC1 - HPPDEAT
(03) HFLB2 - DONTDRES
(-8) HFLC1 - HPPDEAT
(-9) HFLC1 - HPPDEAT

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

HFLC1 - HPPDEAT

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFLD1 - HPPDCHAR
(02) HFLD1 - HPPDCHAR
(03) HFLC2 - DONTEAT
(-8) HFLD1 - HPPDCHAR
(-9) HFLD1 - HPPDCHAR

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

HFLD1 - HPPDCHAR

Page 33 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]

HPPDCHAR

HFLD1

code 1
getting in or out of bed or chairs?

[You said that getting in or out of bed or chairs is something that [you don't/(SP) doesn't] do.]
DONTCHAR

HFLD2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDWALK

HFLE1

code 1
walking?

[You said that walking is something that [you don't/(SP) doesn't] do.]
DONTWALK

HFLE2

code 1
Is this because of a physical, mental, emotional, or memory problem?

[Because of a physical, mental, emotional, or memory problem, [do you/does (SP)] have any difficulty…]
HPPDTOIL

HFLF1

code 1
using the toilet, including getting up and down?

[You said that using the toilet is something that [you don't/(SP) doesn't] do.]
DONTTOIL

HFLF2

yes/no
Is this because of a physical, mental, emotional, or memory problem?

Code List

Routing

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFLE1 - HPPDWALK
(02) HFLE1 - HPPDWALK
(03) HFLD2 - DONTCHAR
(-8) HFLE1 - HPPDWALK
(-9) HFLE1 - HPPDWALK

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

HFLE1 - HPPDWALK

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) HFLF1 - HPPDTOIL
(02) HFLF1 - HPPDTOIL
(03) HFLE2 - DONTWALK
(-8) HFLF1 - HPPDTOIL
(-9) HFLF1 - HPPDTOIL

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

HFLF1 - HPPDTOIL

(01) YES
(02) NO
(03) DOESN'T DO
(-8) Don't Know
(-9) Refused

(01) BOX HFLA1
(02) BOX HFLA1
(03) HFLF2 - DONTTOIL
(-8) BOX HFLA1
(-9) BOX HFLA1

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

BOX HFLA1

BOX HFLA1

routing

IF HFLA1 – HPPDBATH = 1/Yes OR HFLA2 - DONTBATH = 1/Yes, GO TO HFLA3 - HELPBATH.
ELSE GO TO BOX HFLB1.

HELPBATH

HFLA3

yes/no

[[You said [your/(SP's)] health makes bathing or showering difficult./You said that bathing or showering is something (01) YES
[you don't/(SP) doesn't] do.]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with bathing or showering?
(-9) Refused

PCHKBATH

HFLA4

yes/no

Does someone usually stay nearby just in case [you need/(SP) needs] help with bathing or showering?
[That is, does someone usually stay or come into the room to check on [you/him/her]?]

EQIPBATH

HFLA5

yes/no

[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with bathing or showering?

BOX HFLA2

routing

IF HFLA3 – HELPBATH = 1/Yes, GO TO HFLA6 - LONGBATH.
ELSE GO TO BOX HFLB1.

(01) HFLA5 - EQIPBATH
(02) HFLA4 - PCHKBATH
(-8) HFLA4 - PCHKBATH
(-9) HFLA4 - PCHKBATH

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

HFLA5 - EQIPBATH

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

BOX HFLA2

(01) HFLA7 - STILBATH
(02) BOX HFLB1
(03) BOX HFLB1
(-8) BOX HFLB1
(-9) BOX HFLB1

BOX HFLB1

LONGBATH

HFLA6

code 1

How long [have you/has (SP)] needed help with bathing or showering? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

STILBATH

HFLA7

yes/no

Do you expect that [you/(SP)] will still need help with bathing or showering three months from now?

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

BOX HFLB1

routing

IF HFLB1 - HPPDDRES = 1/Yes OR HFLB2 – DONTDRES = 1/Yes, GO TO HFLB3 - HELPDRES.
ELSE GO TO BOX HFLC1.

Page 34 of 49

2021 MCBS Community Questionnaire

HFQ- Health Status and Functioning

Variable Name

MR Screen Name Question Type

Question Text/Description

HELPDRES

HFLB3

yes/no

[[You said [your/(SP's)] health makes dressing difficult./You said that dressing is something [you don't/(SP) doesn't] (01) YES
do.]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with dressing?
(-9) Refused

PCHKDRES

HFLB4

yes/no

Does someone usually stay nearby just in case [you need/(SP) needs] help with dressing?
[That is, does someone usually stay or come into the room to check on [you/him/her]?]

EQIPDRES

Code List

Routing
(01) HFLB5 - EQIPDRES
(02) HFLB4 - PCHKDRES
(-8) HFLB4 - PCHKDRES
(-9) HFLB4 - PCHKDRES

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

HFLB5 - EQIPDRES

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

BOX HFLB2

HFLB5

yes/no

[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with dressing?

BOX HFLB2

routing

IF HFLB3 – HELPDRES = 1/Yes, GO TO HFLB6 - LONGDRES.
ELSE GO TO BOX HFLC1.

LONGDRES

HFLB6

code 1

How long [have you/has (SP)] needed help with dressing? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

(01) HFLB7 - STILDRES
(02) BOX HFLC1
(03) BOX HFLC1
(-8) BOX HFLC1
(-9) BOX HFLC1

STILDRES

HFLB7

yes/no

Do you expect that [you/(SP)] will still need help with dressing three months from now?

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

BOX HFLC1

BOX HFLC1

routing

IF HFLC1 - HPPDEAT = 1/Yes OR HFLC2 – DONTEAT = 1/Yes, GO TO HFLC3 - HELPEAT.
ELSE GO TO BOX HFLD1.

HFLC3

yes/no

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

(01) HFLC5 - EQIPEAT
(02) HFLC4 - PCHKEAT
(-8) HFLC4 - PCHKEAT
(-9) HFLC4 - PCHKEAT

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

HFLC5 - EQIPEAT

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

BOX HFLC2

[[You said [your/(SP's)] health makes eating difficult./You said that eating is something [you don't/(SP) doesn't] do.]]
HELPEAT

[Do you/Does (SP)] receive help from another person with eating?

Does someone usually stay nearby just in case [you need/(SP) needs] help with eating?
PCHKEAT

HFLC4

yes/no
[That is, does someone usually stay or come into the room to check on [you/him/her]?]

EQIPEAT

HFLC5

yes/no

[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with eating?

BOX HFLC2

routing

IF HFLC3 - HELPEAT = 1/Yes, GO TO HFLC6 - LONGEAT.
ELSE GO TO BOX HFLD1.

LONGEAT

HFLC6

code 1

How long [have you/has (SP)] needed help with eating? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

(01) HFLC7 - STILEAT
(02) BOX HFLD1
(03) BOX HFLD1
(-8) BOX HFLD1
(-9) BOX HFLD1

STILEAT

HFLC7

yes/no

Do you expect that [you/(SP)] will still need help with eating three months from now?

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

BOX HFLD1

BOX HFLD1

routing

IF HFLD1 – HPPDCHAR = 1/Yes OR HFLD2 - DONTCHAR = 1/Yes, GO TO HFLD3 - HELPCHAR.
ELSE GO TO BOX HFLE1.

Page 35 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

HELPCHAR

HFLD3

yes/no

[[You said [your/(SP's)] health makes getting in or out of bed or chairs difficult./You said that getting in or out of bed (01) YES
or chairs is something [you don't/(SP) doesn't] do.]]
(02) NO
(-8) Don't Know
[Do you/Does (SP)] receive help from another person with getting in or out of bed or chairs?
(-9) Refused

PCHKCHAR

HFLD4

yes/no

Does someone usually stay nearby just in case [you need/(SP) needs] help with getting in or out of bed or chairs?
[That is, does someone usually stay or come into the room to check on (you/him/her)?]

EQIPCHAR

HFLD5

yes/no

[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with getting in or out of bed or chairs?

BOX HFLD2

routing

IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD6 - LONGCHAR.
ELSE GO TO BOX HFLE1.

Code List

Routing
(01) HFLD5 - EQIPCHAR
(02) HFLD4 - PCHKCHAR
(-8) HFLD4 - PCHKCHAR
(-9) HFLD4 - PCHKCHAR

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

HFLD5 - EQIPCHAR

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

BOX HFLD2

(01) HFLD7 - STILCHAR
(02) BOX HFLE1
(03) BOX HFLE1
(-8) BOX HFLE1
(-9) BOX HFLE1

LONGCHAR

HFLD6

code 1

How long [have you/has (SP)] needed help with getting in or out of bed or chairs? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

STILCHAR

HFLD7

yes/no

Do you expect that [you/(SP)] will still need help with getting in or out of bed or chairs three months from now?

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

BOX HFLE1

BOX HFLE1

routing

IF HFLE1- HPPDWALK = 1/Yes OR HFLE2 – DONTWALK = 1/Yes, GO TO HFLE3 - HELPWALK.
ELSE GO TO BOX HFLF1.

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

(01) HFLE5 - EQIPWALK
(02) HFLE4 - PCHKWALK
(-8) HFLE4 - PCHKWALK
(-9) HFLE4 - PCHKWALK

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

HFLE5 - EQIPWALK

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

BOX HFLE2

[IF R IS IN A WHEELCHAIR OR CANNOT STAND DUE TO PERMANENT DISABILITY ONLY, SELECT "NO"
WITHOUT READING TEXT BELOW.]
HELPWALK

HFLE3

yes/no

[[You said [your/(SP's)] health makes walking difficult./You said that walking is something [you don't/(SP) doesn't]
do.]]
[Do you/Does (SP)] receive help from another person with walking?

[IF R IS IN A WHEELCHAIR OR CANNOT STAND DUE TO PERMANENT DISABILITY ONLY, SELECT "NO"
WITHOUT READING TEXT BELOW.]
PCHKWALK

HFLE4

yes/no

Does someone usually stay nearby just in case [you need/(SP) needs] help with walking?
[That is, does someone usually stay or come into the room to check on (you/him/her)?]

EQIPWALK

HFLE5

yes/no

[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with walking?

BOX HFLE2

routing

IF HFLE3 - HELPWALK = 1/Yes, GO TO HFLE6 - LONGWALK.
ELSE GO TO BOX HFLF1.

LONGWALK

HFLE6

code 1

How long [have you/has (SP)] needed help with walking? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

(01) HFLE7 - STILWALK
(02) BOX HFLF1
(03) BOX HFLF1
(-8) BOX HFLF1
(-9) BOX HFLF1

STILWALK

HFLE7

yes/no

Do you expect that [you/(SP)] will still need help with walking three months from now?

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

BOX HFLF1

Page 36 of 49

2021 MCBS Community Questionnaire

Variable Name

HELPTOIL

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

BOX HFLF1

routing

IF HFLF1 – HPPDTOIL = 1/Yes OR HFLF2 – DONTTOIL = 1/Yes, GO TO HFLF3 - HELPTOIL.
ELSE GO TO BOX HFLA3.

HFLF3

yes/no

[[You said [your/(SP's)] health makes using the toilet difficult./You said that using the toilet is something [you
don't/(SP) doesn't] do.]]
[Do you/Does (SP)] receive help from another person with using the toilet, including getting up and down?

Code List

Routing

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

(01) HFLF5 - EQIPTOIL
(02) HFLF4 - PCHKTOIL
(-8) HFLF4 - PCHKTOIL
(-9) HFLF4 - PCHKTOIL

PCHKTOIL

HFLF4

yes/no

Does someone usually stay nearby just in case [you need/(SP) needs] help with using the toilet, including getting up (01) YES
and down?
(02) NO
(-8) Don't Know
[That is, does someone usually stay or come into the room to check on [you/him/her]?]
(-9) Refused

HFLF5 - EQIPTOIL

EQIPTOIL

HFLF5

yes/no

(01) YES
[Do you/Does (SP)] use special equipment or aids to help [you/him/her] with using the toilet, including getting up and (02) NO
down?
(-8) Don't Know
(-9) Refused

BOX HFLF2

BOX HFLF2

routing

IF HFLF3 - HELPTOIL = 1/Yes, GO TO HFLF6 - LONGTOIL.
ELSE GO TO BOX HFLA3.

LONGTOIL

HFLF6

code 1

How long [have you/has (SP)] needed help with using the toilet? Has it been . . .

(01) less than three months,
(02) three months or more but less than one year, or
(03) one year or more?
(-8) Don't Know
(-9) Refused

STILTOIL

HFLF7

yes/no

Do you expect that [you/(SP)] will still need help with using the toilet three months from now?

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

BOX HFLA3

routing

IF HFLA3 - HELPBATH = 1/Yes, GO TO HFLA9 - PERSON_HLPRBATH.
ELSE GO TO BOX HFLB3.

(01) HFLF7 - STILTOIL
(02) BOX HFLA3
(03) BOX HFLA3
(-8) BOX HFLA3
(-9) BOX HFLA3

BOX HFLA3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
You mentioned that [you receive/(SP) receives] help with bathing and showering. Who gives that help?

IF PERSON_HLPRBATH = (N+1) , GO TO HFLA9_NEWROSTFNAM.
ELSE GO TO BOX HFLB3.

PERSON_HLPRB
HFLA9
ATH

roster

ROSTFNAM

HFLA9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLA9_NEW - ROSTLNAM

ROSTLNAM

HFLA9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLA9_NEW - ROSTREL

ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

Page 37 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLA9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLA9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFLB3

routing

IF HFLB3 - HELPDRES = 1/Yes, GO TO HFLB9 - PERSON_HLPRDRES.
ELSE GO TO BOX HFLC3.

Code List

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

Routing
(01) DO NOT DISPLAY
(02) BOX HFLB3
(03) BOX HFLB3
(04) BOX HFLB3
(05) BOX HFLB3
(06) BOX HFLB3
(07) BOX HFLB3
(08) BOX HFLB3
(09) BOX HFLB3
(10) BOX HFLB3
(11) BOX HFLB3
(12) BOX HFLB3
(13) BOX HFLB3
(14) BOX HFLB3
(50) DO NOT DISPLAY
(51) BOX HFLB3
(52) BOX HFLB3
(53) BOX HFLB3
(54) BOX HFLB3
(55) BOX HFLB3
(56) BOX HFLB3
(57) BOX HFLB3
(91) HFLA9_NEW - ROSTREOS
(-8) BOX HFLB3
(-9) BOX HFLB3

BOX HFLB3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRD
HFLB9
RES

You mentioned that [you receive/(SP) receives] help with dressing. Who gives that help?
roster
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRBATH = (N+1), GO TO HFLB9_NEWROSTFNAM.
ELSE GO TO BOX HFLC3.

ROSTFNAM

HFLB9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLB9_NEW - ROSTLNAM

ROSTLNAM

HFLB9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLB9_NEW - ROSTREL

Page 38 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLB9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLB9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFLC3

routing

IF HFLC3 – HELPEAT = 1/Yes, GO TO HFLC9 - PERSON_HLPREAT.
ELSE GO TO BOX HFLD3.

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFLC3
(03) BOX HFLC3
(04) BOX HFLC3
(05) BOX HFLC3
(06) BOX HFLC3
(07) BOX HFLC3
(08) BOX HFLC3
(09) BOX HFLC3
(10) BOX HFLC3
(11) BOX HFLC3
(12) BOX HFLC3
(13) BOX HFLC3
(14) BOX HFLC3
(50) DO NOT DISPLAY
(51) BOX HFLC3
(52) BOX HFLC3
(53) BOX HFLC3
(54) BOX HFLC3
(55) BOX HFLC3
(56) BOX HFLC3
(57) BOX HFLC3
(91) HFLB9_NEW - ROSTREOS
(-8) BOX HFLC3
(-9) BOX HFLC3

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFLC3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRE
HFLC9
AT

You mentioned that [you receive/(SP) receives] help with eating. Who gives that help?
roster
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPREAT = (N+1) GO TO HFLC9_NEWROSTFNAM.
ELSE GO TO BOX HFLD3.

ROSTFNAM

HFLC9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLC9_NEW - ROSTLNAM

ROSTLNAM

HFLC9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLC9_NEW - ROSTREL

Page 39 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLC9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLC9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFLD3

routing

IF HFLD3 – HELPCHAR = 1/Yes, GO TO HFLD9 - PERSON_HLPRCHAR.
ELSE GO TO BOX HFLE3.

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFLD3
(03) BOX HFLD3
(04) BOX HFLD3
(05) BOX HFLD3
(06) BOX HFLD3
(07) BOX HFLD3
(08) BOX HFLD3
(09) BOX HFLD3
(10) BOX HFLD3
(11) BOX HFLD3
(12) BOX HFLD3
(13) BOX HFLD3
(14) BOX HFLD3
(50) DO NOT DISPLAY
(51) BOX HFLD3
(52) BOX HFLD3
(53) BOX HFLD3
(54) BOX HFLD3
(55) BOX HFLD3
(56) BOX HFLD3
(57) BOX HFLD3
(91) HFLC9_NEW - ROSTREOS
(-8) BOX HFLD3
(-9) BOX HFLD3

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFLD3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
You mentioned that [you receive/(SP) receives] help with getting in or out of bed or chairs. Who gives that help?

IF PERSON_HLPRCHAR = (N+1) , GO TO HFLD9_NEWROSTFNAM.
ELSE GO TO BOX HFLE3.

PERSON_HLPRC
HFLD9
HAR

roster

ROSTFNAM

HFLD9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLD9_NEW - ROSTLNAM

ROSTLNAM

HFLD9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLD9_NEW - ROSTREL

ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

Page 40 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLD9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLD9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFLE3

routing

IF HFLE3 – HELPWALK = 1/Yes, GO TO HFLE9 - PERSON_HLPRWALK.
ELSE GO TO BOX HFLF3.

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFLE3
(03) BOX HFLE3
(04) BOX HFLE3
(05) BOX HFLE3
(06) BOX HFLE3
(07) BOX HFLE3
(08) BOX HFLE3
(09) BOX HFLE3
(10) BOX HFLE3
(11) BOX HFLE3
(12) BOX HFLE3
(13) BOX HFLE3
(14) BOX HFLE3
(50) DO NOT DISPLAY
(51) BOX HFLE3
(52) BOX HFLE3
(53) BOX HFLE3
(54) BOX HFLE3
(55) BOX HFLE3
(56) BOX HFLE3
(57) BOX HFLE3
(91) HFLD9_NEW - ROSTREOS
(-8) BOX HFLE3
(-9) BOX HFLE3

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFLE3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRW
HFLE9
ALK

You mentioned that [you receive/(SP) receives] help with walking. Who gives that help?
roster
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRWALK = (N+1), GO TO HFLE9_NEWROSTFNAM.
ELSE GO TO BOX HFLF3.

ROSTFNAM

HFLE9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLE9_NEW - ROSTLNAM

ROSTLNAM

HFLE9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLE9_NEW - ROSTREL

Page 41 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLE9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLE9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFLF3

routing

IF HFLF3 – HELPTOIL = 1/Yes, GO TO HFLF9 - PERSON_HLPRTOIL.
ELSE GO TO BOX HFL4.

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFLF3
(03) BOX HFLF3
(04) BOX HFLF3
(05) BOX HFLF3
(06) BOX HFLF3
(07) BOX HFLF3
(08) BOX HFLF3
(09) BOX HFLF3
(10) BOX HFLF3
(11) BOX HFLF3
(12) BOX HFLF3
(13) BOX HFLF3
(14) BOX HFLF3
(50) DO NOT DISPLAY
(51) BOX HFLF3
(52) BOX HFLF3
(53) BOX HFLF3
(54) BOX HFLF3
(55) BOX HFLF3
(56) BOX HFLF3
(57) BOX HFLF3
(91) HFLE9_NEW - ROSTREOS
(-8) BOX HFLF3
(-9) BOX HFLF3

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFLF3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRT
HFLF9
OIL

You mentioned that [you receive/(SP) receives] help with using the toilet. Who gives that help?
roster
ENTER ALL HELPERS.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRTOIL = (N+1), GO TO HFLF9_NEWROSTFNAM.
ELSE GO TO BOX HFLG3.

ROSTFNAM

HFLF9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLF9_NEW - ROSTLNAM

ROSTLNAM

HFLF9_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLF9_NEW - ROSTREL

Page 42 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

ROSTREL

HFLF9_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFLF9_NEW

text

[What is the name of the person and relationship to (SP)?]

BOX HFL4

routing

IF MORE THAN ONE PERSON SELECTED AT HFLA9, HFLB9, HFLC9, HFLD9, HFLE9, AND/OR HFLF9, GO TO
HFL10 - PERSON_HLPRMOST.
ELSE GO TO HFM1 - FALLANY.

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) BOX HFLF3
(03) BOX HFLF3
(04) BOX HFLF3
(05) BOX HFLF3
(06) BOX HFLF3
(07) BOX HFLF3
(08) BOX HFLF3
(09) BOX HFLF3
(10) BOX HFLF3
(11) BOX HFLF3
(12) BOX HFLF3
(13) BOX HFLF3
(14) BOX HFLF3
(50) DO NOT DISPLAY
(51) BOX HFLF3
(52) BOX HFLF3
(53) BOX HFLF3
(54) BOX HFLF3
(55) BOX HFLF3
(56) BOX HFLF3
(57) BOX HFLF3
(91) HFLF9_NEW - ROSTREOS
(-8) BOX HFLF3
(-9) BOX HFLF3

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

BOX HFLF3

DISPLAY PERSON ROSTER AS RESPONSE OPTIONS:
1. [PERSON 1]
2. [PERSON 2]
…
(01-N) LIST ALL PERSONS AS RESPONSE OPTIONS
(N+1) ADD ANOTHER
PERSON_HLPRM
HFL10
OST

Which of these persons gives [you/(SP)] the most help with these things?
roster
SELECT ONLY ONE.

DISPLAY:
1 First Name Display ROST.ROSTFNAM.
2 Last Name Display ROST.ROSTLNAM.
3 Relationship to SP Display relationship:
If ROST.ROSTREL=91/Other, display
ROST.ROSTREOS.
Else display ROST.ROSTREL relationship.

IF PERSON_HLPRMOST = (N+1), GO TO
HFLF10_NEW-ROSTFNAM.
ELSE GO TO HFM1 - FALLANY.

ROSTFNAM

HFL10_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLF10_NEW - ROSTLNAM

ROSTLNAM

HFL10_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER

HFLF10_NEW - ROSTREL

Page 43 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

(02) SPOUSE
(03) SON
(04) DAUGHTER
(05) BROTHER
(06) SISTER
(07) FATHER
(08) MOTHER
(09) SON-IN-LAW
(10) DAUGHTER-IN-LAW
(11) GRANDSON
(12) GRANDDAUGHTER
(13) NEPHEW
(14) NIECE
(51) FRIEND/NEIGHBOR
(52) BOARDER
(53) NURSE/NURSE'S AIDE
(54) LEGAL/FINANCIAL OFFICER
(55) GUARDIAN
(56) PARTNER
(57) ROOMMATE
(91) OTHER
(-8) Don't Know
(-9) Refused

(01) DO NOT DISPLAY
(02) HFM1 - FALLANY
(03) HFM1 - FALLANY
(04) HFM1 - FALLANY
(05) HFM1 - FALLANY
(06) HFM1 - FALLANY
(07) HFM1 - FALLANY
(08) HFM1 - FALLANY
(09) HFM1 - FALLANY
(10) HFM1 - FALLANY
(11) HFM1 - FALLANY
(12) HFM1 - FALLANY
(13) HFM1 - FALLANY
(14) HFM1 - FALLANY
(50) DO NOT DISPLAY
(51) HFM1 - FALLANY
(52) HFM1 - FALLANY
(53) HFM1 - FALLANY
(54) HFM1 - FALLANY
(55) HFM1 - FALLANY
(56) HFM1 - FALLANY
(57) HFM1 - FALLANY
(91) HFLF10_NEW - ROSTREOS
(-8) HFM1 - FALLANY
(-9) HFM1 - FALLANY

ROSTREL

HFL10_NEW

code one

[What is the name of the person and relationship to (SP)?]

ROSTREOS

HFL10_NEW

text

[What is the name of the person and relationship to (SP)?]

(01) CONTINUOUS ANSWER
(-8) Don't Know
(-9) Refused

HFM1 - FALLANY

FALLANY

HFM1

yes/no

Since (LAST HF MONTH YEAR), [have you/has (SP)] fallen down?

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

(01) HFM2 - FALLTIME
(02) BOX MH1
(-8) BOX MH1
(-9) BOX MH1

FALLTIME

HFM2

numeric

[Continuous answer.]
Don't Know
Refused

HFM3A - FALLHELP

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

HFM3B - FALCODE

(01) BROKEN BONE/FRACTURE
(02) SPRAIN/STRAIN
(03) BRUISE
(04) CUT/WOUND/LACERATION
(05) CONCUSSION
(06) DISLOCATION
(91) OTHER
(96) NO INJURY
(-8) Don't Know
(-9) Refused

(01) HFM3C - FALLIMIT
(02) HFM3C - FALLIMIT
(03) HFM3C - FALLIMIT
(04) HFM3C - FALLIMIT
(05) HFM3C - FALLIMIT
(06) HFM3C - FALLIMIT
(91) HFM3B - FALOTHOS
(96) HFM3C - FALLIMIT
(-8) HFM3C - FALLIMIT
(-9) HFM3C - FALLIMIT

OTHER (SPECIFY)

(01) [Continuous answer.]

HFM3C - FALLIMIT
(01) HFM3D - FALLBACK
(02) HFM3E - FALLFEAR
(-8) HFM3E - FALLFEAR
(-9) HFM3E - FALLFEAR

HFM3E - FALLFEAR

Since (LAST HF MONTH YEAR), how many times [have you/has (SP)] fallen down?
ENTER "95" IF 95 OR MORE FALLS REPORTED.

FALLHELP

HFM3A

yes/no

Thinking about the [most recent) time that [you/(SP)] fell, did [you/he/she] hurt [yourself/himself/herself] badly
enough to get medical help?

What kind of injury did [you/(SP)] have in that [most recent] fall?
FALCODE

HFM3B

code all

[PROBE: Anything else?]
CHECK ALL THAT APPLY.

FALOTHOS

HFM3B

verbatim text

FALLIMIT

HFM3C

yes/no

Did [your/(SP's)] [most recent] fall cause [you/him/her] to limit [your/his/her] regularacivities activities?

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

FALLBACK

HFM3D

code 1

How long did it take [you/(SP)] to get back to regular activities after [your/his/her] [most recent] fall?

(01) LESS THAN ONE WEEK
(02) ONE WEEK OR MORE
(03) NEVER RESUMED REGULAR ACTIVITIES
(-8) Don't Know
(-9) Refused

Page 44 of 49

2021 MCBS Community Questionnaire

HFQ- Health Status and Functioning

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

FALLFEAR

HFM3E

How would you rate [your/(SP's)] fear of falling on a scale of 1 to 6, where 1 is "Not at all afraid of falling" and 6 is
"Extremely afraid of falling"?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

numeric

Routing

BOX MH1 DISUPPYR

SHOW CARD HF8
This card lists some examples of different types of dietary supplements.
DISUPPYR

DISUPPYR

yes/no

(01) YES
(02) NO
Since (LAST HF MONTH YEAR), [have you/has (SP)] used or taken any vitamins, minerals, herbals or other dietary (-8) Don't Know
supplements? Include prescription and non-prescription supplements.
(-9) Refused

(01) MULTVTYR
(02) BOX MH1
(-8) BOX MH1
(-9) BOX MH1

[IF NEEDED: Include any supplements that you have already told me about.]

MULTVTYR

VITSUPYR

MULTVTYR

VITSUPYR

yes/no

Since (LAST HF MONTH YEAR), did [you/(SP)] take any multivitamins, such as One a Day, Theragran, or Centrum
type multivitamins?
(01) YES
(02) NO
[IF NEEDED: Multivitamins may be pills, liquids, or packets]
(-8) Don't Know
(-9) Refused
[IF NEEDED: Include any multivitamins that you have already told me about.]

VITSUPYR

select all

(01) Calcium (with or without vitamin D)
(02) Choline
(03) Coenzyme Q
(04) Eye health supplement (such as Ocuvite
PreserVision or I-Caps)
(05) Fiber supplement (such as Metamucil or Benefiber)
(06) Folate or folic acid
SHOW CARD HF9
(07) Garlic supplement
(08) Iron
Please look at the vitamins and dietary supplements listed on this card. Since (LAST HF MONTH YEAR), what
(09) Joint supplement (such as glucosamine, with or
vitamins and dietary supplements did [you/(SP)] take at least once?
without chondroitin or other ingredients)
(10) Magnesium
Do not include vitamins and dietary supplements that are taken as part of a multivitamin.
(11) Melatonin
(12) Niacin
[IF NEEDED: Include any vitamins or dietary supplements (that are not part of a multivitamin) that you have already
(13) Omega-3 (ALA/DHA/EPA) or fish oil
told me about.]
(14) Potassium
(15) Probiotics (in pill, powder, or liquid form)
IF RESPONDENT HAS PROVIDED YOU WITH SUPPLEMENT BOTTLES YOU MAY USE THOSE TO ANSWER
(16) Saw palmetto
THE QUESTION IF THE SUPPLEMENT WAS TAKEN SINCE (LAST HF MONTH YEAR).
(17) Vitamin A
(18) Vitamin B-12
SELECT ALL THAT APPLY
(19) Vitamin B-complex
(20) Vitamin C
(21) Vitamin D (NOT as part of a calcium supplement)
(22) Vitamin E
(23) Zinc
(91) Other Supplement(s)
(-8) Don't Know
(-9) Refused

(01)-(23) BOX MH1
(91) VITOTHOS
(-8) BOX MH1
(-9) BOX MH1

What were the names of those other supplements?
ENTER UP TO 5 ADDITIONAL SUPPLEMENTS AT THIS SCREEN.
VITOTHOS

VITOTHOS

text

IF RESPONDENT REPORTS MORE THAN 5 OTHER SUPPLEMENTS, ENTER THE SUPPLEMENTS THAT
WERE TAKEN THE MOST OFTEN SINCE (LAST HF MONTH YEAR).

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

VITOTHO2

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

VITOTHO3

[INSERT TEXT BOX 1 FOR SUPPLEMENT 1]

VITOTHO2

VITOTHOS

text

[INSERT TEXT BOX 2 FOR SUPPLEMENT 2]

Page 45 of 49

2021 MCBS Community Questionnaire

HFQ- Health Status and Functioning

Variable Name

MR Screen Name Question Type

Question Text/Description

Code List

Routing

VITOTHO3

VITOTHOS

text

[INSERT TEXT BOX 3 FOR SUPPLEMENT 3]

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

VITOTHO4

VITOTHO4

VITOTHOS

text

[INSERT TEXT BOX 4 FOR SUPPLEMENT 4]

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

VITOTHO5

VITOTHO5

VITOTHOS

text

[INSERT TEXT BOX 5 FOR SUPPLEMENT 5]

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

BOX MH1

BOX MH1

routing

If the respondent is a proxy (SPPROXY=2), go to HFQ1 - LOSTURIN.
Else go to HFN1 - HFGAD1.

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN2 - HFGAD2

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN3 - HFPHQ1

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN4 - HFPHQ2

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN5 - HFPHQ3

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN6 - HFPHQ4

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN7 - HFPHQ5

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN8 - HFPHQ6

The next few questions ask about the last two weeks.
SHOW CARD HF8
HFGAD1

HFN1

list
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious, or on edge

SHOW CARD HF8
HFGAD2

HFN2

list

[Over the last 2 weeks, how often have you been bothered by the following problems?]
Not being able to stop or control worrying.

SHOW CARD HF8
HFPHQ1

HFN3

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
little interest or pleasure in doing things? Would you say…

SHOW CARD HF8
HFPHQ2

HFN4

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling down, depressed, or hopeless?

SHOW CARD HF8
HFPHQ3

HFN5

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble falling or staying asleep, or sleeping too much?

SHOW CARD HF8
HFPHQ4

HFN6

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling tired or having little energy?

SHOW CARD HF8
HFPHQ5

HFN7

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
poor appetite or overeating?

Page 46 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description
SHOW CARD HF8

HFPHQ6

HFN8

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
feeling bad about yourself – or that you are a failure or have let yourself or your family down?

SHOW CARD HF8
HFPHQ7

HFN9

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
trouble concentrating on things, such as reading the newspaper or watching TV?

SHOW CARD HF8
HFPHQ8

HFN10

list

[Over the last 2 weeks, how often have you been bothered by the following problems:]
moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless
that you have been moving around a lot more than usual?

BOX HFPHQ

routing

Code List

Routing

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN9 - HFPHQ7

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

HFN10 - HFPHQ8

(01) NOT AT ALL
(02) SEVERAL DAYS
(03) MORE THAN HALF THE DAYS
(04) NEARLY EVERY DAY
(-8) REFUSED
(-9) DON’T KNOW

BOX HFPHQ

(01) Not at all difficult,
(02) Somewhat difficult,
(03) Very difficult,
(04) Extremely difficult?
(-8) REFUSED
(-9) DON’T KNOW

HFQ1 - LOSTURIN

IF SP REPORTED [(02/Several Days), (03/More than half the days), or (04/Nearly Every Day)] TO AT LEAST ONE
ITEM IN HFPHQ1 THROUGH HFPHQ8, GO TO HFN11-PHQ9QS10.
ELSE GO TO HFQ1 – LOSTURIN.
SHOW CARD HF9

PHQ9QS10

HFN11

code one

You mentioned that you have been bothered by the following problems over the last 2 weeks:
[LIST ALL CONDITIONS WHERE ANSWER RECORDED DOES NOT EQUAL 1/NOT AT ALL, -8/REFUSED, or 9/DON’T KNOW, AT HFPHQ1 THROUGH HFPHQ8]
How difficult have these problems made it for you to do your work, take care of things at home, or get along with
people?

SHOW CARD HF10

(01) MORE THAN ONCE A WEEK
(02) ABOUT ONCE A WEEK
(03) 2-3 TIMES A MONTH
(04) ABOUT ONCE A MONTH
(05) EVERY 2-3 MONTHS
(06) ONCE OR TWICE A YEAR
(07) NOT AT ALL
(08) SP IS ON DIALYSIS OR CATHETERIZATION OR
UROSTOMY OR BLADDER BAG
(-8) Don't Know
(-9) Refused

(01) HFQ2 - TALKURIN
(02) HFQ2 - TALKURIN
(03) HFQ2 - TALKURIN
(04) HFQ2 - TALKURIN
(05) HFQ2 - TALKURIN
(06) HFQ2 - TALKURIN
(07) BOX HFT1
(08) BOX HFT1
(-8) BOX HFT1
(-9) BOX HFT1

LOSTURIN

HFQ1

code 1

I'd like to ask about a health problem that is more common than people think. Please look at this card and tell me
how often, if at all, since (LAST HF MONTH YEAR) [you have/(SP) has] lost urine because [you/he/she] could not
control [your/his/her] bladder.

TALKURIN

HFQ2

yes/no

[Have you/Has (SP)] talked about this problem with [your/(SP’s)] doctor or other health professional?

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

(01) HFQ3 - FEELURIN
(02) BOX HFT1
(-8) BOX HFT1
(-9) BOX HFT1

FEELURIN

HFQ3

yes/no

Has [your/(SP’s)] doctor or other health professional asked [you/him/her] about how [you/he/she] feel[s] about this
problem?

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

HFQ4 - REASURIN

REASURIN

HFQ4

yes/no

Has [your/(SP’s)] doctor or other health professional examined [you/him/her] to figure out why [you/he/she]
[lose/loses] urine?

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

HFQ5 - SURGURIN

SURGURIN

HFQ5

yes/no

Has [your/(SP’s)] doctor or other health professional talked with [you/him/her] about taking medicine or having
surgery for this problem?

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

BOX HFT1

Page 47 of 49

2021 MCBS Community Questionnaire

Variable Name

HFQ- Health Status and Functioning

MR Screen Name Question Type

Question Text/Description

BOX HFT1

IF HFJ2 - OCHBP = 1/Yes, GO TO HFT1 - HYPETOLD.
ELSE GO TO BOX HFEND.

routing

We have recorded that [you were/(SP) was] told by a doctor or other health professional that [you had/he had/she
had] hypertension, also called high blood pressure.
HYPETOLD

HFT1

code 1

[Were you/Was (SP)] told on two or more different medical visits that [you/he/she] had high blood pressure or
hypertension?
[EXPLAIN IF NECESSARY: We are interested in knowing whether [your/(SP’s)] blood pressure was high for more
than one reading.]

Code List

Routing

(01) YES
(02) NO
(03) SP NEVER HAD HIGH BLOOD
PRESSURE/PREVIOUS RESPONSE ENTERED IN
ERROR
(-8) Don't Know
(-9) Refused

(01) HFT2 - HYPEAGE
(02) HFT2 - HYPEAGE
(03) BOX HFEND
(-8) HFT2 - HYPEAGE
(-9) HFT2 - HYPEAGE

HFT2

numeric

(01) [Continuous answer.]
How old [were you/was (SP)] when [you were/he was/she was] first told that [you/he/she] had high blood pressure? (-8) Don't Know
(-9) Refused

HYPEAGE_LESS
HFT2
ONE

numeric

How old [were you/was (SP)] when (you were/he was/she was) first told that [you/he/she] had high blood pressure?

(01) LESS THAN ONE YEAR OLD
(-7) Empty

HFT6D - HYPEHOME

HYPEHOME

HFT6D

yes/no

Because of [your/his/her] high blood pressure, [are you/is (SP)] now measuring [your/his/her] blood pressure at
home?

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

HFT6G - HYPEMEDS

HYPEMEDS

HFT6G

yes/no

Because of [your/his/her] high blood pressure, [are you/is (SP)] now taking prescribed medicine for [your/his/her]
high blood pressure?

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

HFT6J - HYPEDRNK

HYPEDRNK

HFT6J

yes/no

[Have you/Has (SP)] cut down on drinking alcoholic beverages because of [your/his/her] high blood pressure?]

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

BOX HFT2

BOX HFT2

routing

IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT7 - HYPELONG.
ELSE GO TO HFT12A - HYPECTRL.

HFT7

numeric

How long [have you/has (SP)] been treated with prescribed medicines for [your/his/her] high blood pressure?

(01) [Continuous answer.]
(-8) Don't Know
(-9) Refused

HFT7 - HYPELONG_LESSONE

HYPELONG_LESS
HFT7
ONE

numeric

How long [have you/has (SP)] been treated with prescribed medicines for [your/his/her] high blood pressure?

(01) LESS THAN ONE YEAR
(-7) Empty

BOX HFT3

BOX HFT3

routing

IF SP IS IN THE SUPPLEMENTAL SAMPLE (sample_person.INTTYPE=3), GO TO HFT8 - HYPEMANY.
ELSE GO TO HFT11A - HYPECOND.

HYPEMANY

HFT8

numeric

(01) [Continuous answer.]
(-8) Don't Know
[WE ARE ASKING ABOUT HOW MANY DIFFERENT PRESCRIBED MEDICINES FOR HIGH BLOOD PRESSURE
(-9) Refused
ARE TAKEN BY THE RESPONDENT, NOT THE NUMBER OF PILLS THEY MIGHT TAKE IN ONE DAY.]

HFT11A - HYPECOND

HYPECOND

HFT11A

code 1

How often [do you/does (SP)] have trouble with side effects from [your/his/her] blood pressure medicines[s]? Please (01) ALWAYS
tell me if [you/he/she] always, sometimes, or never [have/has] trouble with side effects.
(02) SOMETIMES
(03) NEVER
[EXPLAIN IF NECESSARY: By "side effects", I mean that the medicine causes any condition such as fatigue,
(-8) Don't Know
headache, or coughing.]
(-9) Refused

HFT12A - HYPECTRL

HFT12A

code 1

(01) VERY CONFIDENT
Doctors and other health professionals often recommend changing your habits or lifestyle, such as changing your
(02) CONFIDENT
diet, or getting regular exercise in order to control blood pressure. How confident are you that [you/(SP)] can follow
(03) SOMEWHAT CONFIDENT
these recommendation?
(04) NOT AT ALL CONFIDENT
(-8) Don't Know
Would you say that you are very confident, confident, somewhat confident, or not at all confident?
(-9) Refused

BOX HFT4

BOX HFT4

routing

IF HFT6G - HYPEMEDS = 1/Yes, GO TO HFT13 - HYPEPAY.
ELSE GO TO BOX HFEND.

HYPEAGE

HYPELONG

HFT2 - HYPEAGE_LESSONE

How many different prescribed medicines [do you/does (SP)] take for [your/his/her] high blood pressure?

HYPECTRL

Page 48 of 49

2021 MCBS Community Questionnaire

Variable Name

MR Screen Name Question Type

HFQ- Health Status and Functioning

Question Text/Description

Code List

Routing

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

HFT14 - HYPESKIP

HYPEPAY

HFT13

yes/no

[Do you/Does (SP)] have difficulty paying for the medicine[s] [your/his/her] doctor or other health professional
prescribes for [your/his/her] high blood pressure?

HYPESKIP

HFT14

yes/no

(01) YES
[Do you/Does (SP)] ever skip taking [your/his/her] medicine, take less medicine than prescribed, or share medicine (02) NO
because of the cost of the medicine?
(-8) Don't Know
(-9) Refused

BOX HFEND

routing

If INTTYPE in(C003), go to PXQ
Else, GO TO NAQ.

BOX HFEND

Page 49 of 49