Quality (Priority Conditions) Supplement (PC) Section
BOX_01
======
OMITTED.
PC01
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
Now I would like to ask you a few questions about some health
conditions (PERSON) may have and the course of treatment
(PERSON) received. You may have already mentioned some of these
conditions and treatments, however I still need to ask about
each one.
PRESS ENTER TO CONTINUE.
BOX_01A
=======
----------------------------------------------------
| IF PERSON IS < 18 YEARS OF AGE OR IN AGE |
| CATEGORIES 1-3, CONTINUE WITH PC01A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PC02 |
----------------------------------------------------
PC01A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Let’s talk about the last time (PERSON) had a sore throat that
was serious enough to cause you to contact a doctor or other
health professional.
Did this happen during the past 12 months?
YES .................................... 1
NO ..................................... 2 {PC02}
REF ................................... -7 {PC02}
DK .................................... -8 {PC02}
PC01B
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Was that primarily because (PERSON) had a sore throat or was it
primarily for other symptoms?
SORE THROAT ............................ 1
OTHER SYMPTOMS ......................... 2 {PC02}
REF ................................... -7 {PC02}
DK .................................... -8 {PC02}
[Code One]
PC01C
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did (PERSON) actually see a doctor or other health professional
for this sore throat?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC01D
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did a doctor or other health professional prescribe an
antibiotic for (PERSON)?
YES .................................... 1
NO ..................................... 2 {PC02}
REF ................................... -7 {PC02}
DK .................................... -8 {PC02}
PC01E
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did a doctor or other health professional give (PERSON) a
throat swab before giving (PERSON) the antibiotic prescription?
YES .................................... 1 {PC02}
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC01F
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did any of the other people in this household have similar
symptoms around the same time as (PERSON)?
YES .................................... 1
NO ..................................... 2 {PC02}
REF ................................... -7 {PC02}
DK .................................... -8 {PC02}
PC01G
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did a doctor or other health professional do a throat swab
for (that person/those other people)?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC01H
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did a doctor or other health professional prescribe an
antibiotic for (that person/those other people)?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC02
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
{Other than during pregnancy, (have/has)/(Have/Has)} (PERSON)
ever been told by a doctor or health professional that
(PERSON) (have/has) diabetes or sugar diabetes?
YES .................................... 1
NO ..................................... 2 {PC04}
REF ................................... -7 {PC04}
DK .................................... -8 {PC04}
PRESS F1 FOR DEFINITION OF DIABETES.
----------------------------------------------------
| DISPLAY ‘Other than during pregnancy, (have/has)’ |
| IF PERSON BEING ASKED ABOUT IS FEMALE AND IS > 9 |
| YEARS OF AGE OR IN AGE CATEGORIES 3-9. DISPLAY |
| ‘(Have/Has)’ IF PERSON BEING ASKED ABOUT IS MALE |
| OR IS FEMALE AND IS <= 9 YEARS OF AGE OR IN AGE |
| CATEGORIES 1-2. |
----------------------------------------------------
PC03
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
PID: XXX
AGE: XXX
STATUS: {CURRENT/INSTITUTIONALIZED/DECEASED}
DETERMINE IF SELF OR PROXY DIABETES CARE SUPPLEMENT (DCS)
SHOULD BE DISTRIBUTED:
SELF DCS: FOR ANY CURRENT RU MEMBER WHO IS 18 YEARS OF AGE OR
OLDER.
PROXY DCS: FOR ANY CURRENT RU MEMBER WHO IS LESS THAN 18 YEARS OF
AGE. ALSO FOR ANY RU MEMBER WHO IS 18 OR OLDER AND IS
INSTITUTIONALIZED, DECEASED, OR OTHERWISE INCAPACITATED.
CODE TYPE OF DCS DISTRIBUTED FOR (PERSON).
SELF ................................... 1 {PC03A}
PROXY .................................. 2
[Code One]
PC03OV1
=======
CODE REASON FOR PROXY DCS.
CHILD UNDER 18 ......................... 1 {PC03A}
OTHER .................................. 2
[Code One]
PC03OV2
=======
SPECIFY OTHER REASON FOR PROXY DCS.
[Enter Other Specify] ..................
----------------------------------------------------
| DISPLAY "CURRENT" IF PERSON BEING ASKED ABOUT IS A|
| CURRENT RU MEMBER AND IS NOT DECEASED OR |
| INSTITUTIONALIZED. DISPLAY "INSTITUTIONALIZED" |
| IF PERSON BEING ASKED ABOUT IS FLAGGED AS |
| 'INSTITUTIONALIZED' FOR THE CURRENT ROUND. |
| DISPLAY “DECEASED” IF PERSON BEING ASKED ABOUT |
| IS FLAGGED AS ‘DECEASED’ FOR THE CURRENT ROUND. |
----------------------------------------------------
PC03A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME}
PID: XXX DOB: XX/XX/XXXX
PREPARE {SELF/PROXY} DIABETES CARE SUPPLEMENT (DCS): WRITE IN
PERSON NAME, PID, DATE OF BIRTH, AGE, AND RUID.
HAND PREPARED {SELF/PROXY} DCS TO RESPONDENT AND SAY:
The care of people with diabetes is an interest of the Public
Health Service. We hope that {(PERSON)/you or someone else in
the family} would be able to fill out this short questionnaire
on the care (PERSON) get(s) for (PERSON)'s diabetes. {(PERSON)/
You} can give it to me before I leave today, or I can pick it
up later.
PRESS ENTER TO CONTINUE.
----------------------------------------------------
| DISPLAY "SELF" AND "(PERSON)" IF PC03 IS CODED '1'|
| (SELF). DISPLAY "PROXY", "you or someone else in |
| the family" AND "You" IF PC03 IS CODED '2' (PROXY)|
----------------------------------------------------
PC04
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) ever been told by a doctor or other health
professional that (PERSON) (have/has) asthma?
YES .................................... 1
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
PRESS F1 FOR DEFINITION OF ASTHMA.
PC04A
=====
(Do/Does) (PERSON) still have asthma?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC05
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
During the past 12 months, (have/has) (PERSON) had an episode
of asthma or an asthma attack?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PRESS F1 FOR DEFINITION OF ASTHMA ATTACK.
BOX_01B
=======
----------------------------------------------------
| IF PC04A IS CODED ‘1’ (YES) OR IF PC05 IS CODED |
| ‘1’ (YES), CONTINUE WITH PC05A |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE (IF PC04A IS CODED ‘2’ (NO), ‘-7’ (REF) |
| OR ‘-8’ (DK) AND PC05 IS CODED ‘2’ (N0), ‘-7’ |
| (REF) OR ‘-8’ (DK)), GO TO BOX_02 |
----------------------------------------------------
PC05A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Now I am going to ask you about two different kinds of asthma
medicine. One is for quick relief. The other does not give
quick relief but protects your lungs and prevents symptoms over
the long term.
During the past 3 months, (have/has) (PERSON) used the kind of
prescription inhaler that you breathe in through your mouth that
gives quick relief from asthma symptoms?
YES .................................... 1
NO ..................................... 2 {PC06A}
REF ................................... -7 {PC06A}
DK .................................... -8 {PC06A}
PC05B
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
During the past 3 months, did (PERSON) use more than three
canisters of this type of inhaler?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC06A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) ever taken the preventive kind of asthma
medicine used every day to protect your lungs and keep you
from having attacks? Include both oral medicine and inhalers.
This is different from inhalers used for quick relief.
YES .................................... 1
NO ..................................... 2 {PC08}
REF ................................... -7 {PC08}
DK .................................... -8 {PC08}
PC06B
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
(Are/Is) (PERSON) now taking this medication (that protects
the lungs) daily or almost daily?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC06
====
OMITTED.
PC07
====
OMITTED.
PC08
====
{PERSON’S FIRST MIDDLE AND LAST NAME}
A peak flow meter measures how hard you can blow air out of
your lungs. (Do/Does) (PERSON) currently have a peak flow meter
at home?
YES .................................... 1
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
PC08A
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
Did (PERSON) ever use the peak flow meter?
YES .................................... 1
NO ..................................... 2 {BOX_02}
REF ................................... -7 {BOX_02}
DK .................................... -8 {BOX_02}
PC08B
=====
{PERSON’S FIRST MIDDLE AND LAST NAME}
SHOW CARD PC-2
When did (PERSON) last use the peak flow meter? Was it
within the last seven days, more than seven days ago but
within the last thirty days, or more than thirty days ago?
WITHIN LAST 7 DAYS ..................... 1
MORE THAN 7, BUT WITHIN LAST 30 DAYS ... 2
MORE THAN 30 DAYS AGO .................. 3
REF ................................... -7
DK .................................... -8
[Code One]
BOX_02
======
----------------------------------------------------
| IF PERSON IS => 18 YEARS OF AGE OR IN AGE |
| CATEGORIES 4-9, CONTINUE WITH PC09 |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO BOX_03 |
----------------------------------------------------
PC09
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
{Other than during pregnancy, (have/has)/(Have/Has)} (PERSON)
ever been told by a doctor or other health professional that
(PERSON) had hypertension, also called high blood pressure?
YES .................................... 1
NO ..................................... 2 {PC11}
REF ................................... -7 {PC11}
DK .................................... -8 {PC11}
PRESS F1 FOR DEFINITION OF HYPERTENSION.
----------------------------------------------------
| DISPLAY ‘Other than during pregnancy, (have/has)’ |
| IF PERSON BEING ASKED ABOUT IS FEMALE AND IS > 9 |
| YEARS OF AGE OR IN AGE CATEGORIES 3-9. DISPLAY |
| ‘(Have/Has)’ IF PERSON BEING ASKED ABOUT IS MALE |
| OR IS FEMALE AND IS <= 9 YEARS OF AGE OR IN AGE |
| CATEGORIES 1-2. |
----------------------------------------------------
PC10
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Were/Was) (PERSON) told on two or more different visits
that (PERSON) had hypertension, also called high blood pressure?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC11
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
About how long has it been since (PERSON) had (PERSON)'s blood
pressure checked by a doctor, nurse or other health professional?
WITHIN PAST YEAR ....................... 1
WITHIN PAST 2 YEARS .................... 2
WITHIN PAST 3 YEARS .................... 3 {PC11A}
WITHIN PAST 5 YEARS .................... 4 {PC11A}
MORE THAN 5 YEARS ...................... 5 {PC11A}
NEVER .................................. 6 {PC11A}
REF ................................... -7 {PC11A}
DK .................................... -8 {PC11A}
PRESS F1 FOR DEFINITION OF BLOOD PRESSURE CHECK.
[Code One]
PC11OV
======
IF NOT ALREADY GIVEN, ASK: About how long ago in months has it
been?
IF LESS THAN ONE MONTH AGO, ENTER 0.
[Enter Number-2] .......................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| RANGE CHECK: 0 TO 24 |
----------------------------------------------------
PC11A
=====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) ever been told by a doctor or other health
professional that (PERSON) had high cholesterol?
YES .................................... 1
NO ..................................... 2 {PC12}
REF ................................... -7 {PC12}
DK .................................... -8 {PC12}
PC11B
=====
{PERSON'S FIRST MIDDLE AND LAST NAME}
How old (were/was) (PERSON) when the high cholesterol was first
diagnosed?
IF LESS THAN ONE YEAR OLD WHEN DIAGNOSED, ENTER 0 FOR AGE.
[ENTER AGE-3] ..........................
REF ................................... -7
DK .................................... -8
----------------------------------------------------
| RANGE CHECK: 0 TO PERSON’S CURRENT AGE |
----------------------------------------------------
PC12
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) ever been told by a doctor or other health
professional that (PERSON) had ...
1 = YES
2 = NO
PC12_01
=======
...Coronary heart disease? ( )
PC12_02
=======
...Angina, also called angina pectoris? ( )
PC12_03
=======
...A heart attack, also called myocardial
infarction or MI? ( )
PC12_04
=======
...Any other kind of heart condition or heart
disease, other than coronary heart disease,
angina, or heart attack? ( )
----------------------------------------------------
| IF CODED '1' (YES), CONTINUE WITH PC12_04OV |
----------------------------------------------------
----------------------------------------------------
| OTHERWISE, GO TO PC12_05 |
----------------------------------------------------
PC12_04OV
=========
What did the doctor or other health professional call it?
[Enter Other Specify-45] ...............
REF ................................... -7
DK .................................... -8
PC12_05
=======
{(Have/Has) (PERSON) ever been told by a doctor or other health
professional that (PERSON) had ...}
...A stroke or TIA? A TIA is a transient
ischemic attack which is sometimes referred
to as a ministroke. ( )
----------------------------------------------------
| DISPLAY ‘(Have/Has) (PERSON)... that (PERSON) |
| had...’ IF PC12_04 IS CODED ‘1’ (YES). OTHERWISE,|
| DISPLAY ‘[Have/Has...’ |
----------------------------------------------------
PC12_06
=======
...Emphysema? ( )
----------------------------------------------------
| REFUSED (-7) AND DON'T KNOW (-8) ALLOWED ON ALL |
| ENTRY FIELDS. |
----------------------------------------------------
----------------------------------------------------
| GO TO PC13 |
----------------------------------------------------
PC13
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
Doctors or other health professionals often advise people to
make a change to their lifestyles to lower their risk of
developing a number of diseases, including heart disease.
Has a doctor or other health professional ever advised
(PERSON) to...
1 = YES
2 = NO
PC13_01
=======
...Eat fewer high fat or high cholesterol foods? ( )
PC13_02
=======
...Exercise more? ( )
----------------------------------------------------
| REFUSED (-7) AND DON'T KNOW (-8) ALLOWED ON ALL |
| ENTRY FIELDS. |
----------------------------------------------------
PC14
====
COMBINED WITH PC13
PC15
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Do/Does) (PERSON) take aspirin every day or every other day?
YES .................................... 1 {PC18}
NO ..................................... 2
REF ................................... -7 {PC18}
DK .................................... -8 {PC18}
PC16
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Do/Does) (PERSON) have a health problem or condition that makes
taking aspirin unsafe for (PERSON)?
YES .................................... 1
NO ..................................... 2 {PC18}
REF ................................... -7 {PC18}
DK .................................... -8 {PC18}
PC17
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
Is that problem stomach related or something else?
STOMACH RELATED ........................ 1
SOMETHING ELSE ......................... 2
REF ................................... -7
DK .................................... -8
[Code One]
PC18
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) had pain, aching, stiffness or swelling
around a joint in the last 12 months?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
PC19
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Have/Has) (PERSON) ever been told by a doctor or other health
professional that (PERSON) had arthritis?
YES .................................... 1
NO ..................................... 2 {BOX_03}
REF ................................... -7 {BOX_03}
DK .................................... -8 {BOX_03}
PC20
====
{PERSON'S FIRST MIDDLE AND LAST NAME}
(Are/Is) (PERSON) currently being treated by a doctor or other
health professional for (PERSON)'s arthritis?
YES .................................... 1
NO ..................................... 2
REF ................................... -7
DK .................................... -8
BOX_03
======
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| GO TO NEXT QUESTIONNAIRE SECTION |
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