SASH Participant Survey

Form Approved

OMB No. 0990-

Exp. Date XX/XX/20XX

SASH Participant

Survey

Sponsored by

The U.S. Department of Health and Human Services

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 20 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

Survey Instructions Answer each question by marking the box to the left of your answer. Yes No Your Health 1. Please think about the health care provider you see most often. In the last 12 months, how many times did you visit this provider to get care for yourself? 1 None 2 1 time 3 2 4 3 5 4 6 5 to 9 7 10 or more times 2. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much? 2a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf? 1 Yes, limited a lot 2 Yes, limited a little 3 No, not limited at all 2b. Climbing several flights of stairs? 1 Yes, limited a lot 2 Yes, limited a little 3 No, not limited at all 3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health? 3a. Accomplished less than you would like? 1 Yes 2 No		3b. Were limited in the kind of work or other activities? 1 Yes 2 No 3c. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? 1 Not at all 2 A little bit 3 Moderately 4 Quite a bit 5 Extremely 4. Please indicate which statement best describes your own health state today? 4a. Mobility 1 I have no problems in walking about 2 I have some problems in walking about 3 I am confined to bed 4b. Self-Care 1 I have no problems with self-care 2 I have some problems washing or dressing myself 3 I am unable to wash or dress myself 4c. Usual activities (e.g. work, study, housework, family or leisure activities) 1 I have no problems with performing my usual activities 2 I have some problems performing my usual activities 3 I am unable to perform my usual activities 4d. Pain/Discomfort 1 I have no pain or discomfort 2 I have moderate pain or discomfort 3 I have extreme pain or discomfort 4e. Anxiety/Depression 1 I am not anxious or depressed 2 I am moderately anxious or depressed 3 I am extremely anxious or depressed
	5. Because of a health or physical problem, do you have any difficulty doing the following activities without special equipment or help from another person? 5a. Bathing 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity 5b. Dressing 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity 5c. Eating 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity 5d. Getting in or out of chairs 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity 5e. Walking 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity 5e. Using the toilet 1 No, I do not have difficulty 2 Yes, I have difficulty 3 I am unable to do this activity Your Medications 6. Below is a list of problems that people sometimes have with their medicines. Please check how hard it is for you to do each of the following: 6a. Open or close the medication bottle 1 very hard 2 somewhat hard 3 not hard at all		6b. Read the print on the bottle 1 very hard 2 somewhat hard 3 not hard at all 6c. Remember to take all the pills 1 very hard 2 somewhat hard 3 not hard at all 6d. Get your refills in time 1 very hard 2 somewhat hard 3 not hard at all 6e. Take so many pills at the same time 1 very hard 2 somewhat hard 3 not hard at all Your Diet 7. The next questions are about your recent diet. 7a. Has your food intake declined over the past 3 months due to loss of appetite, digestive problems, chewing or swallowing difficulties? 1 severe loss of appetite 2 moderate loss of appetite 3 no loss of appetite 7b. How many full meals do you eat each day? 1 1 meal 2 2 meals 3 3 meals 7c. Do you eat at least one serving of dairy products (milk, cheese, yogurt) each day? 1 Yes 2 No 7d. Do you eat at two or more servings of peas, beans or eggs each week? 1 Yes 2 No

7e. Do you eat meat, fish, or poultry every day? 1 Yes 2 No 7f. Do you eat two or more servings of fruits or vegetables per day? 1 Yes 2 No 7g. How much fluid (water, juice, coffee, tea, milk) do you consume per day? 1 less than 3 cups 2 3 to 5 cups 3 more than 5 cups 7h. Which of the following best describe how you are fed? 1 I’m unable to eat without assistance 2 I’m able to fee myself with some difficulty 3 I can feed myself without any problems 7i. How would you describe your nutritional status? 1 I think I’m malnourished 2 I’m uncertain about my nutritional state 3 I don’t think I have any nutritional problems About You 8. In general, how would you rate your overall health? 1 Excellent 2 Very good 3 Good 4 Fair 5 Poor 9. What is your age? 1 18 to 24 2 25 to 34 3 35 to 44 4 45 to 54 5 55 to 64 6 65 to 74 7 75 to 84 8 85 or older

10. Are you male or female? 1 Male 2 Female 11. What is the highest grade or level of school that you have completed? 1 8th grade or less 2 Some high school, but did not graduate 3 High school graduate or GED 4 Some college or 2-year degree 5 4-year college graduate 6 More than 4-year college degree 12. Are you of Hispanic or Latino origin or descent? 1 Yes, Hispanic or Latino 2 No, not Hispanic or Latino 13. What is your race? Mark one or more. 1 White 2 Black or African American 3 Asian 4 Native Hawaiian or Other Pacific Islander 5 American Indian or Alaskan Native 6 Other 14. Did someone help you complete this survey? 1 Yes 2 No → Thank you. Please return the completed survey in the postage-paid envelope. 15. How did that person help you? Mark one or more. 1 Read the questions to me 2 Wrote down the answers I gave 3 Answered the questions for me 4 Translated the questions into my language 5 Helped in some other way

Thank you

Please return the completed survey in the postage-paid envelope.