MH Provider Interview

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

ATTACHMENT 6

CLIENT PHYSICAL EXAM AND SURVEY

SECTION 1: PHYSICAL EXAM

Format

• Brief physical exam conducted by external contractor

Content

Primary

• Blood pressure: systolic and diastolic. Measured with digital sphygmomanometer

• BMI:

  • Weight (kg) – measured with standard medical scale

  • Height (cm) – measured with measuring stick built into standard medical scale

• HgbA1c or blood sugar: from blood sample – finger stick

• Total Cholesterol: from blood sample – finger stick

• HDL: from blood sample – finger stick

• LDL: from blood sample – finger stick

• Triglycerides: from blood sample – finger stick

Secondary

• Waist circumference

• Tobacco: Urinary or salivary cotinine for any tobacco use (cigarettes, cigars or smokeless)

• Breath CO (ppm) for smoking status

SECTION 2: BRIEF INTERVIEW

Format

• Structured, in-person survey administered at the time of the PH assessment by external contractor

• Approximately 5-10 minutes in length

• Items below include select items from the NOMS tool and supplemental items specific to PBHCI

Content Areas

DEMOGRAPHICS

Question	Response Options	Source
Today’s date	MM/DD/YY
What is your gender?	Male, Female, Transgender, Other (Specify), Refused	NOMS
Are you Hispanic or Latino?	Yes, No, Refused	NOMS
What race do you consider yourself? Please answer yes or no for each of the following. You may say yes to more than one.		NOMS
Black or African American	Yes, No, Refused	NOMS
Asian	Yes, No, Refused	NOMS
Native Hawaiian or other Pacific Islander	Yes, No, Refused	NOMS
Alaska Native	Yes, No, Refused	NOMS
White	Yes, No, Refused	NOMS
American Indian	Yes, No, Refused	NOMS
What is your month and year of birth?	MM/YY, Refused	NOMS

DAILY FUNCTIONING

Question	Response Options	Source
In order to provide the best possible mental health and related services, we need to know what you think about how well you were able to deal with your everyday life during the past 30 days. Please indicate your disagreement/agreement with each of the following statements.
I deal effectively with daily problems	Strongly disagree, Disagree, Agree, Strongly agree, Refused	NOMS
I am able to control my life	Strongly disagree, Disagree, Agree, Strongly agree, Refused	NOMS
I am getting along with my family	Strongly disagree, Disagree, Agree, Strongly agree, Refused, not applicable	NOMS
My housing situation is satisfactory	Strongly disagree, Disagree, Agree, Strongly agree, Refused	NOMS
My symptoms are not bothering me	Strongly disagree, Disagree, Agree, Strongly agree, Refused	NOMS

TOBACCO / DRUG / ALCOHOL

Question	Response Options	Source
In the past 30 days, how often have you used…
Tobacco products (cigarettes, chewing tobacco, cigars, etc.)	Never, Once or twice, Weekly, Daily or almost daily, Refused, Don’t know	NOMS
[If respondent smokes cigarettes] How soon after waking do you smoke your first cigarette of the day?	<5 minutes, 6-30 minutes, 31-60 minutes, >60 minutes, Refused, Don’t know	Heaviness of Smoking Index (2-item Fagerstrom)
[If respondent smokes cigarettes] How many cigarettes do you smoke per day?	>30, 21-30, 11-20, 1-10, Refused	Heaviness of Smoking Index (2-item Fagerstrom)
Alcoholic beverages (beer, wine, liquor, etc.)?	Never, Once or twice, Weekly, Daily or almost daily, Refused	NOMS
[If ≥ once or twice and respondent male] How many times in the past 30 days have you had five or more drinks in a day? [Clarify if needed] A standard drink = 12oz beer, 5 oz wine, 1.5 oz liquor	Never, Once or twice, Weekly, Daily or almost daily, Refused, Don’t know	NOMS
[If ≥ once or twice and respondent female] How many times in the past 30 days have you had four or more drinks in a day? [Clarify if needed] A standard drink = 12oz beer, 5 oz wine, 1.5 oz liquor	Never, Once or twice, Weekly, Daily or almost daily, Refused, Don’t know	NOMS
Have you used an illegal drug to get high? (e.g., marijuana, cocaine, heroin, etc.)	Never, Once or twice, Weekly, Daily or almost daily, Refused, Don’t know	Original item
Have you used a prescription drug or for some purpose other than to treat a medical or mental health condition? (e.g., Xanax, Valium, Oxycodone, Percocet)	Never, Once or twice, Weekly, Daily or almost daily, Refused, Don’t know	Original item

HOUSING

Question	Response Options	Source
In the past 30 days, where have you been living most of the time?	Owned or rented house, apartment, trailer, room; Someone else’s house, apartment, trailer, room; Homeless (shelter, street/outdoors, park), Group home; Adult foster care; Transitional living facility; Hospital (medical); Hospial (psychiatric); Detox/inpatient or residential substance abuse treatment facility; Correctional facility (jail/prison); Nursing home; VA Hospital; Veteran’s home; Military base, Other housed (specify); Refused; Don’t know	NOMS

EDUCATION / EMPLOYMENT / CRIME

Question	Response Options	Source
What is the highest level of education you have finished, whether or not you received a degree?	Less than 12th grade; 12th grade/High school diploma/equivalent (GED), Voc/Tech diploma, Some college or university, Bachelor’s degree (BA, BS), Graduate work/Graduate degree, Refused, Don’t know	NOMS
Are you currently enrolled in school or a job training program?	Not enrolled, Enrolled full time, Enrolled part time, Other (specify), Refused, Don’t know	NOMS
Are you currently employed? [Clarify by focusing on status during most of the previous week, determining whether the consumer worked at all or had a regular job but was off work].	Employed full time (35+ hours per week, or would have been), Employed part time, Unemployed – looking for work, Unemployed – disabled, Unemployed – volunteer work, Unemployed – retired, Unemployed – not looking for work, Other (specify), Refused, Don’t know	NOMS
In the past 30 days, how many times have you been arrested?	#times, Refused, Don’t know	NOMS

PERCEPTION OF CARE

Question	Response Options	Source
Staff here believe that I can grow, change, and recover.	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
Staff helped me obtain the information I needed so that I could take charge of managing my illness.	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
I, not staff, decided my treatment goals.	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
If I had other choices, I would still get services from this agency.	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS

SOCIAL CONNECTEDNESS

Question	Response Options	Source
I am happy with the friendships I have	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
I have people with whom I can do enjoyable things	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
I feel I belong in my community	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS
In a crisis, I would have the support I need from family or friends.	Strongly disagree, Disagree, Undecided, Agree, Strongly agree, Refused	NOMS

SERVICE UTILIZATION

Question	Response Options	Source
In the last 30 days, what services have you used?		NOMS
Medical care	Yes, No, Refused, Don’t know	NOMS
Employment services	Yes, No, Refused, Don’t know	NOMS
Family services	Yes, No, Refused, Don’t know	NOMS
Child care	Yes, No, Refused, Don’t know	NOMS
Transportation	Yes, No, Refused, Don’t know	NOMS
Education services	Yes, No, Refused, Don’t know	NOMS
Housing support	Yes, No, Refused, Don’t know	NOMS
Social recreational activities	Yes, No, Refused, Don’t know	NOMS
Consumer operated services	Yes, No, Refused, Don’t know	NOMS
HIV testing	Yes, No, Refused, Don’t know	NOMS

DIET / NUTRITION

Question	Response Options	Source
Are you on any kind of diet, either to lose weight or for some other health-related reason?	Yes, No, Refused, Don’t know	NHANES
The next questions ask how often you have certain types of food available at home.
How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits.	Always, Most of the time, Sometimes, Rarely, Never, Refused, Don’t know	NHANES
How often do you have any dark green vegetables at home? This includes fresh, dried, canned, and frozen.	Always, Most of the time, Sometimes, Rarely, Never, Refused, Don’t know	NHANES - adapted
How often do you have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk. [Do not include soy milk]	Always, Most of the time, Sometimes, Rarely, Never, Refused, Don’t know	NHANES - adapted

PHYSICAL ACTIVITY AND PHYSICAL FITNESS

Question	Response Options	Source
During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time.	0 – 7 days, Refused, Don’t know	NHANES – adapted
Over the past 30 days, on average how many hours per day did you sit and watch TV or videos?	<1h, 1h, 2h, 3h, 4h, 5h or more, None, Refused, Don’t know	NHANES – adapted

PHYSICAL HEALTH AND HEALTH CARE

Question	Response Options	Source
How would you rate your overall health right now?	Excellent, Very good, Good, Fair, Poor, Refused, Don’t Know	NOMS
What kind of place do you usually go to when you are sick or need advice about your health? Is it a clinic, doctor’s office, emergency room, or some other place?	Clinic or health center, Doctor’s office or HMO, Hospital emergency room, Hospital Outpatient Department, Some other place, Refused, Don’t know	NHANES - adapted
About how long has it been since you last saw or talked to a doctor or other health care professional about your health? Include doctors seen while you were a patient in a hospital.	6 months or less, more than 6 months but not more than 1 year ago, more than 1 year but not more than 3 years ago, more than 3 years, or never; refused, don’t know	NHANES

MEDICATIONS AND SIDE EFFECTS

Question	Response Options	Source
Do you take prescription drugs on a regular basis?	Yes, No, Refused	National Survey on Prescription Drugs
Do you take three or more prescription drugs on a regular basis?	Yes, No, Refused	National Survey on Prescription Drugs
Do you currently have more than 5 prescription drugs in your medicine cabinet?	Yes, No, Refused	National Survey on Prescription Drugs
How many of your prescription medications are for mental health problems?	#, Refused, Don’t know	Original item
How many of your prescription medications are for physical health problems?	#, Refused, Don’t know	Original item

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