4-month Follow up Assessment Survey

4-month Follow-up Assessment Survey Out, Proud and Healthy Fitness OMB No. 0990-

Exp Date

XX/XX/20XX

4-Month Follow-Up

Assessment Survey

Perceived Stress Scale

The following questions ask you about your feelings and thoughts DURING THE LAST MONTH. In each case, check the box indicating how often you felt or thought that way.

	Very often	Fairly often	Some times	Almost never	Never
In the last month, how often have you been upset because of something that happened unexpectedly
In the last month, how often have you felt that you were unable to control the important things in your life.
In the last month, how often have you felt nervous and “stressed?”
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you found that you could NOT cope with all things that you had to do?
In the last month, how often have you been able to control irritations in your life?
In the last month, how often have you felt that you were on top of things?
In the last month, how often have you been angered because of things that were outside of your control?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Connor-Davidson Resiliency Scale (CD-RISC)*

Please indicate how much you agree with the following statements as they apply to you over the last month. If a particular situation has not occurred recently, answer according to how you think you would have felt.

	Not true at all	Rarely true	Sometimes true	Often true	True nearly all the time
I am able to adapt when changes occur	1	2	3	4	5
I can deal with whatever comes my way	1	2	3	4	5
I try to see the humorous side of things when I am faced with problems	1	2	3	4	5
Having to cope with stress can make me stronger	1	2	3	4	5
I tend to bounce back after illness, injury, or other hardships	1	2	3	4	5
I believe I can achieve my goals, even if there are obstacles	1	2	3	4	5
Under pressure, I stay focused and think clearly	1	2	3	4	5
I am not easily discouraged by failure	1	2	3	4	5
I can usually find something to laugh about	1	2	3	4	5
I think of myself as a strong person when dealing with life’s challenges and difficulties	1	2	3	4	5
I am able to handle unpleasant or painful feelings like sadness, fear and anger	1	2	3	4	5

Center for Epidemiologic Studies Depression (CES-D) Scale

Below is a list of the ways you might have felt or behaved. Mark how often you have felt this way during the past week.

In the past week:	Rarely or none of the time (less than 1 day)	Some of a little of the time (1-2 days)	Occasionally or a moderate amount of time (3-4 days)	Most or all of the time (5-7 days)
I felt depressed
I felt lonely
I had crying spells
I felt sad

International Physical Activity Questionnaire (IPAQ) – Short*

We are interested in finding out about the kinds of physical activities that people do as part of their everyday lives. The questions will ask you about the time you spent being physically active in the last 7 days. Please answer each question even if you do not consider yourself to be an active person. Please think about the activities you do at work, as part of your house and yard work, to get from place to place, and in your spare time for recreation, exercise or sport.

Think about all the vigorous activities that you did in the last 7 days. Vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

1. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling?

_____ days per week

No vigorous physical activities Skip to question 3

2. How much time did you usually spend doing vigorous physical activities on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Think about all the moderate activities that you did in the last 7 days. Moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. Think only about those physical activities that you did for at least 10 minutes at a time.

3. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking.

_____ days per week

No moderate physical activities Skip to question 5

4. How much time did you usually spend doing moderate physical activities on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Think about the time you spent walking in the last 7 days. This includes at work and at home, walking to travel from place to place, and any other walking that you might do solely for recreation, sport, exercise, or leisure.

5. During the last 7 days, on how many days did you walk for at least 10 minutes at a time?

_____ days per week

No walking Skip to question 7

6. How much time did you usually spend walking on one of those days?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

The last question is about the time you spent sitting on weekdays during the last 7 days. Include time spent at work, at home, while doing course work and during leisure time. This may include time spent sitting at a desk, visiting friends, reading, or sitting or lying down to watch television.

7. During the last 7 days, how much time did you spend sitting on a week day?

_____ hours per day

_____ minutes per day

Don’t know/Not sure

Eating Out and Food/Drink Consumption Questions

Next, we have some questions about your eating habits and about meals. Meals mean breakfast, lunch and dinner.

1. In general, how healthy is your overall diet? Would you say …..

Excellent

Very good

Good

Fair

Poor

Don’t Know

2. During the past 7 days, how many meals did you get that were prepared away from home in places such as restaurants, fast food places, food stands, grocery stores, or from vending machines?

___________

Number of meals

3. How many of those meals did you get from a fast-food or pizza place?

___________

Number of meals

Some grocery stores sell “ready to eat” foods such as salads, soups, chicken, sandwiches and cooked vegetables in their salad bars and deli counters.

4. During the past 30 days, how often did you eat “ready to eat” foods from the grocery store? [Please do not include sliced meat or cheese you buy for sandwiches and frozen or canned foods.]

Circle the unit

___________ per day or per week or per month

Number of times

5. During the past 30 days, how often did you eat frozen meals or frozen pizzas?

Circle the unit

___________ per day or per week or per month

6. *During the past month, how many times per day, week or month did you drink 100% PURE fruit juices? Do not include fruit-flavored drinks with added sugar or fruit juice you made at home and added sugar to. Only include 100% juice.

________Times per (circle one) day week month never don’t know

7. *During the past month, not counting juice, how many times per day, week or month did you eat fruit? Count fresh, frozen or canned fruit.

________Times per (circle one) day week month never don’t know

8. *During the past month, how many times per day, week or month did you eat cooked or canned beans, such as refried, black, garbanzo beans, beans in soup, soybeans, edamame, tofu or lentils. Do NOT include long green beans.

________Times per (circle one) day week month never don’t know

9. *During the past month, how many times per day, week or month did you eat dark green vegetables for example broccoli or dark leafy greens including romaine, chard, collard greens or spinach?

________Times per (circle one) day week month never don’t know

10. *During the past month, how many times per day, week or month did you eat orange colored vegetables such as sweet potatoes, pumpkin, winter squash or carrots?

________Times per (circle one) day week month never don’t know

11. *Not counting questions 9 & 10, during the past month, about how many times per day, week or month did you eat OTHER vegetables? Examples of other vegetables include tomatoes, tomato juice or V-8 juice, corn, eggplant, lettuce, cabbage and white potatoes that are not fried such as baked or mashed potatoes.

________Times per (circle one) day week month never don’t know

12. *How many servings of fruits and vegetables do you usually have per day? (1 serving = 1 medium piece of fruit; ½ cup fresh, frozen or canned fruits/vegetables; ¾ cup fruit/vegetable juice; 1 cup salad greens; or ¼ cup dried fruit)

□ 0 servings per day

□ 1-2 servings per day

□ 3-4 servings per day

□ 5 or more servings per day

13. *During the past month, how often did you drink regular soda or pop that contains sugar? Do not include diet soda, juices or teas.

________Times per (circle one) day week month don’t know

14. *During the past month, how often did you drink sports or energy drinks such as Gatorade, Red Bull and Vitamin Water? Do not include diet or sugar-free kinds.

________Times per (circle one) day week month don’t know

15. *During the past month, how often did you drink sweetened fruit drinks such as Kool-aid, cranberry drink and lemonade? Include fruit drinks you made at home and added sugar to. Do not include 100% fruit juices and drinks with things like Splenda or Equal.

________Times per (circle one) day week month don’t know

16. *During the past month, how often did you drink coffee or tea with sugar or honey added? DO not include drinks with things like Splenda or Equal. Include pre-sweetened tea and coffee drinks such as Arizona Iced Tea and Frappuccino.

________Times per (circle one) day week month don’t know

17. *In the past month, how often did you drink water (including tap, bottled, and carbonated water)?

________Times per (circle one) day week month don’t know

18. * Each time you drank water, how much did you usually drink?

Less than 6 fl oz (3/4 oz)

8 fl oz (1 cup)

12 fl oz (1-1/2 cups)

16 fl oz (2 cups)

More than 20 fl oz (2-1/2 cups)

By a drink we mean half an ounce of absolute alcohol (e.g. a 12 ounce can or glass of beer or cooler, a 5 ounce glass of wine, or a drink containing 1 shot of liquor).

19. *During the last 30 days, how often did you usually have any kind of drink containing alcohol? Choose only one.

□ Every day

□ 5 to 6 times a week

□ 3 to 4 times a week

□ twice a week

□ once a week

□ 2 to 3 times a month

□ once a month

□ I did not drink any alcohol in the past month, but I did drink in the past (done with alcohol Q)

□ I never drank any alcohol in my life (done with alcohol Q)

20. *During the last 30 days, how many alcoholic drinks did you have on a typical day when you drank alcohol?

□ 25 or more drinks

□ 19 to 24 drinks

□ 16 to 18 drinks

□ 12 to 15 drinks

□ 9 to 11 drinks

□ 7 to 8 drinks

□ 5 to 6 drinks

□ 3 to 4 drinks

□ 2 drinks

□ 1 drink

21. *During the last 30 days, how often did you have 4 or more drinks containing any kind of alcohol in within a two-hour period? Choose only one.

□ Every day

□ 5 to 6 days a week

□ 3 to 4 days a week

□ two days a week

□ one day a week

□ 2 to 3 days a month

□ one day a month

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-xxxx . The time required to complete this information collection is estimated to average 4 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