Lawndale Christian Health Center
Patient Centered Care Collaboration
ATTACHMENT 2
PATIENT PARTICIPANT SURVEYS
FOR
DIABETES, HYPERTENSION, OBESITY
CHICAGO
Screening Questionnaire
Form Approved
OMB No. 0990-
Exp. Date XX/XX/20XX
S
Name of Participant: _____________________ Date: ______/ ______/______
Interviewer: _______________________
The following questions will help us ensure you are eligible to take part in this class. If anything I ask you makes you feel uncomfortable, please let me know and we can skip to the following question.
How old are you? _______
○ ELIGIBLE- person is older than 18 and younger than 66
years
○ INELIGIBLE- person is younger than 18 or 66 and older
What is your racial/ethnic group?
○ Hispanic/Latino
○ Non-Hispanic Black or African American
○ Other (specify) ______________________
○ ELIGIBLE- person is Hispanic/Latino or African
American
○ INELIGIBLE- person is not Hispanic/Latino or African
American
If the interviewee is a woman:
Are you currently pregnant, or do you plan to get pregnant in the next 3 months?
Yes
No
○ ELIGIBLE- person is NOT pregnant does NOT plan a
pregnancy in the next 3 months
○ INELIGIBLE- person is pregnant or plan to be pregnant
in the next 3 months
Have you been diagnosed with any one of the following conditions by a medical care provider?
Type 2 diabetes
High blood pressure
○ ELIGIBLE- person has been diagnosed with diabetes or
high blood pressure
○ INELIGIBLE- person has NOT been diagnosed with
diabetes or high blood pressure
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0990- . The time required to complete this information collection is estimated to average (5 minutes) per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Health & Human Services, OS/OCIO/PRA, 200 Independence Ave., S.W., Suite 336-E, Washington D.C. 20201, Attention: PRA Reports Clearance Officer
Have you been diagnosed with any one of the following conditions by a medical care provider?
Heart attack
Stroke
Kidney disease
Seizure
Any other serious condition (specify)___________________________________
○ ELIGIBLE- person has NOT been diagnosed with any of
these conditions
○ INELIGIBLE- person has been diagnosed with ANY of
these conditions
Have you been told by a health care provider that you need to lose weight?
Yes
No
○ ELIGIBLE- person is overweight
○ INELIGIBLE- person is not overweight
Have you abused any drug or substances in the last three months?
Yes
No
○ ELIGIBLE- person has NOT abused any non-prescribed
drugs or substances
○ INELIGIBLE- person has abused non-prescribed drugs or
substances in last 3 months
Interviewer – indicate if the person shows signs of being incoherent, disoriented, intoxicated, etc.
○ ELIGIBLE- person is coherent and oriented
○ INELIGIBLE- person is incoherent or disoriented.
During the next 3 months, will you be traveling out of town?
Yes
No
○ ELIGIBLE- person will NOT be traveling
○ INELIGIBLE- person will be traveling
Do you prefer to take the classes in English or Spanish?
○ English
○ Spanish
Pre UIC Form Page -
| File Type | application/msword |
| File Title | DIABETES BRIEF INTAKE TOOL |
| Last Modified By | Department of Health and Human Services |
| File Modified | 2012-01-19 |
| File Created | 2012-01-19 |