Intake Questionnaire HELP

Lawndale Christian Health Center

Patient Centered Care Collaboration

INTAKE QUESTIONNAIRE

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

Intake Questionnaire

Health Empowerment Lifestyle Program (HELP)

We would like to ask you some questions about your background, your health, self-care activities, and diabetes knowledge. This information will be used to help us understand your service and informational needs, and to improve our health education program. Your answers are confidential. Let us know if you have any questions before we begin.

Code name of participant: _____________________________________ Case Number __ __ __

Name of Interviewer (if needed): ________________________________

HELP program provided in: [ ] Spanish [ ] English

Date of Completion: _________________________

Demographics

A. First, we want to ask you some basic questions about yourself and your living situation.
Race/Ethnicity: [ ] 1. African-American [ ] 2. Hispanic/Latino
Country of Birth: [ ] 1. U.S. [ ] 2. Mexico [ ] 3. Other ______________________ Number of years lived in U.S. ________
Age (years):	Sex: [ ] 1. Female [ ] 2. Male
Primary Language: [ ] 1. English [ ] 2. Spanish [ ] 3. Other ___________________	Education (years):

B. Next, I have a few questions related to your general health care.
1. In the past year, how many times were you seen by a health care provider?
2. In the past year, have you had trouble understanding what your doctor or other health care professional was telling you about your medical condition(s)?	Y N

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 (40 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

C. The questions that follow ask about your self-care activities during the past 7 days before you started HELP. If you were sick during those 7 days, think back to the last 7 days that you were not sick. Please circle your answer.
Diet: On how many of the last 7 days before you started HELP did you …
1. Eat five or more servings of fruits and vegetables?	0	1	2	3	4	5	6	7
2. Space carbohydrates (for example, bread, potatoes, pasta, or rice) evenly throughout the day?	0	1	2	3	4	5	6	7
3. Eat high fat foods such as red meat or full-fat dairy products (for example, whole milk, sour cream, cheese or ice cream)?	0	1	2	3	4	5	6	7
4. Add table salt to your meals?	0	1	2	3	4	5	6	7
5. Avoid canned or pre-packaged food items?	0	1	2	3	4	5	6	7
Exercise: On how many of the last 7 days before you started HELP did you …
6. Participate in at least 30 minutes of physical activity? [Total minutes of continuous activity, including walking.]	0	1	2	3	4	5	6	7
7. Participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?	0	1	2	3	4	5	6	7
Blood Sugar Testing, Blood Pressure and Foot Care: On how many of the last 7 days before you started HELP did you …
8. Test your blood sugar?	0	1	2	3	4	5	6	7
9. Test your blood sugar the number of times recommended by your health care provider?	0	1	2	3	4	5	6	7
10. Test your blood pressure at home?	0	1	2	3	4	5	6	7
11. Check your feet?	0	1	2	3	4	5	6	7
12. Inspect the inside of your shoes?	0	1	2	3	4	5	6	7
Medication: On how many of the last 7 days before you started HELP did you …?
13. Take your recommended diabetes medication?	0	1	2	3	4	5	6	7
14. Take your other recommended medications?	0	1	2	3	4	5	6	7
15. Take at least one aspirin pill?	0	1	2	3	4	5	6	7
Smoking: On how many of the past 7 days before you started HELP did you…?
16. Smoke a cigarette-even one puff- ?	0	1	2	3	4	5	6	7
17. How many cigarettes did you smoke on an average day? Number of cigarettes ____

D. The next set of questions test your knowledge of DIABETES, and its causes and effects. Circle your answer T for True; F for False; DK for don’t know.
The choices I make can affect my blood sugar levels.	T F DK
If I am diabetic, my children have a higher chance of being diabetic.	T F DK
A person with diabetes should visit the eye doctor at least once a year.	T F DK
Regular exercise will increase the need for insulin or other diabetic medication.	T F DK
I can help another person with diabetes by sharing my medication with them.	T F DK
A person with diabetes should drink plenty of water.	T F DK
A person with diabetes should take extra care when cutting their toenails.	T F DK
The way I prepare my food is as important as the food I eat.	T F DK
Shaking and sweating are signs of high blood sugar.	T F DK
Too low blood sugar should be treated immediately.	T F DK
Tight elastic hose or socks are not bad for diabetics.	T F DK
A diabetic diet consists mostly of special foods.	T F DK

E. The next set of questions test your knowledge of overweight/obesity, and its causes and effects. Circle your answer T for True; F for False; DK for don’t know.
1. Carrying extra weight affects blood pressure.	T F DK
2. I can change my weight if I choose to.	T F DK
3. Losing only 10% of the extra weight is enough to improve my health.	T F DK
4. The fat accumulated in the abdomen is different than the fat in the rest of the body	T F DK
5. Obesity is hereditary and there is nothing I can do to avoid being/ becoming obese.	T F DK
6. Obesity is a disease like diabetes or hypertension.	T F DK
7. The portion sizes at restaurants have decreased over the last 30 years.	T F DK
8. Cooking my own meals gives me control over what I eat.	T F DK
9. Balance between diet and daily activity is an effective treatment for obesity	T F DK
10. The ideal weight loss diet helps me lose 1 to 2 pounds per week.	T F DK

F. The next set of questions test your knowledge of high blood pressure, and its causes and effects. Circle your answer T for True; F for False; DK for don’t know.
1. High blood pressure may be associated with stroke.	T F DK
2. High blood pressure is hereditary and there is nothing that can be done to reduce the chances of getting it.	T F DK
3. People with high blood pressure need to reduce salt in their diet.	T F DK
4. Cold and flu medicines may be dangerous for people with high blood pressure.	T F DK
5. Exercise helps to reduce blood pressure.	T F DK
6. A blood pressure of 140/ 110 is considered to be normal.	T F DK
7. People who take fluid pills (diuretics) for high blood pressure may benefit from eating more bananas.	T F DK
8. People with high blood pressure need to reduce animal fat in their diet.	T F DK
9. Smoking does not affect the blood pressure.	T F DK
10. People who are taking medication for high blood pressure should stop taking it if they feel well.	T F DK

G. The questions below are about how confident you are in doing certain things to manage your diabetes or other health problems. Check the box in the column that best describes how you feel.	Ratings: 1 = Not at all confident; 2 = Somewhat Confident; 3 = Very Confident;
How confident do you feel that you…..	1	2	3
1. … know how to read and understand food labels?
2. ... can follow your diet when you have to prepare or share food with other people who do not have diabetes or hypertension?
3. … can choose the appropriate foods to eat when you are hungry (for example, snacks)?
4. … can exercise 15 to 30 minutes, 4 to 5 times a week?
5. … can do something to prevent your blood sugar level from dropping when you exercise?
6. … know what to do when your blood sugar level goes higher or lower than it should be?
7. …can judge when the changes in your illness mean you should visit the doctor?
8. … can control your diabetes so that it does not interfere with the things you want to do?
9. … know how to make healthy food choices?
10. … know what to do to maintain your blood pressure under control?
H. These questions are about HOW YOU FEEL and how things have been with you during the past month. For each question, please circle the one number that comes closest to the way you have been feeling.	Ratings: 0 = Not at all; 1 = Some of the time; 2 = Most of the time;
How much in the past 4 weeks, has your health interfered with your...	0	1	2
1. …normal social activities with family, friends, neighbors, or groups?
2. … hobbies or recreational activities?
3. …household chores?
4. …errands and shopping?

I. These questions are about how you feel and how things have been with you during the past month. For each question, please circle the one number that comes closest to the way you have been feeling.	Ratings: 0 = Not at all; 1 = Some of the time; 2 = Most of the time;
How much time during the past 4 weeks ...	0	1	2
1. …were you discouraged by your health problems?
2. … were you fearful about your future health?
3. …was your health a worry in your life?
4. …were you frustrated by your health problems?

J. To be completed by staff.

1. A1C Pre: ___________________

2. Weight _____________ Height ____ feet ____ inches BMI _______________

3. Blood Pressure ___________________

4. Waist Circumference _____________________

We would like to know how you heard about this health program. Please check all answers that apply.

1. How did you learn about this health program?

1. Through personal contact with a:

□ Friend, neighbor, or relative

□ Health care professional

□ Social service professional

□ Other ________________________________________________________

2. Through written materials I read:

□ Brochure

□ Direct mail

□ Other _______________________________________________________

3. Through social media/electronic materials I read:

□ Email

□ Telephone text message

□ Facebook posting

□ Other _______________________________________________________

The statements below describe attitudes and beliefs you may have about why you signed up for the health program and about your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5= I strongly agree
	1	2	3	4	5
2. Why did you sign up for the program?
I need help managing my health condition
I need information on my health condition
The classes will be taught by a trained professional (community health worker, health educator, pharmacist)
The class will be taught in my language
The materials will be written in my language
Someone will call me to follow-up on what I learn and remind me of what I should do to manage my health
It is easy to get to the program location
It will not take a lot of my time
It does not cost me anything
The statements below describe attitudes and beliefs you may have about the health program you signed up for and your health condition(s): diabetes, hypertension, or being overweight. Please rate how much you agree or disagree with each one by placing a check mark in the appropriate box.	1 = I strongly disagree 2 = I somewhat disagree 3 = I’m neutral 4 = I somewhat agree 5= I strongly agree
	1	2	3	4	5
3. I will learn new information to help me to manage my health condition
4. I will get useful information about my health condition
5. I expect to put what I learn from this program into practice
6. I expect to see positive changes in myself if I do what they teach me
7. I can do something to improve my health condition
8. It is very important to take care of your health
9. I am ready to improve my health

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