CMS-10509 Wellness Program Participant Surveys
Prospective Evaluation of Evidence-Based Community Wellness and Prevention Programs (CMS-10509)
OMB_Wellness_Eval_Part_A_Attachment_3_Participant_Surveys_08122014_clean
Program Participants Survey
OMB: 0938-1252
Part A, Attachment 3
Wellness Program Participant Surveys
Part A, Attachment 3 – Wellness Program Participant Surveys
Contents:
Cover Letter, Initial Distribution, Baseline Participant Survey
Cover Letter, Initial Distribution, Baseline Participant Survey (Spanish)
Cover Letter, Follow-up Distribution, Baseline Participant Survey
Cover Letter, Follow-up Distribution, Baseline Participant Survey (Spanish)
Follow-up Phone Script, Participant Survey
Follow-up Phone Script, Participant Survey (Spanish)
Baseline Participant Survey
Cover Letter, Initial Mailing, 6- and 12-month Follow-up Participant Survey
Cover Letter, Initial Mailing, 6- and 12-month Follow-up Participant Survey (Spanish)
Cover Letter, Follow-up Mailing, 6- and 12-month Follow-up Participant Survey
Cover Letter, Follow-up Mailing, 6- and 12-month Follow-up Participant Survey (Spanish)
Six-month Follow-up Participant Survey
Twelve-month Follow-up Participant Survey
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Dear [NAME]:
I am writing to ask you to take part in an important survey about wellness and disease prevention. The Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare, is gathering information about your experiences managing your health and staying well. We want to make sure that you receive the best possible care so it is important that we hear about your experiences.
You are being asked to complete this survey because you are a Medicare beneficiary who recently attended a wellness program that is a partner in this study. In the survey, we ask about your general health, managing your health, and preventing illness and injury. This survey is voluntary, and your participation will not affect your Medicare benefits. Your answers will be kept confidential.
Results from the survey will be used by Medicare to understand how community wellness programs affect the health and wellbeing of Medicare Beneficiaries.
We appreciate your taking the time to participate in our survey. Thank you in advance for your cooperation. If you have any questions about the survey, please call [insert Westat 800 number] or send an email to [insert Westat email address].
Si desea recibir una copia en español de los materiales de esta encuesta, sírvase llamar al [#] o enviar un correo electrónico a [[email protected]].
Sincerely,
Erin Colligan, PhD, MPP
CMS Project Officer
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Estimado(a) [NAME]:
Por medio de la presente le pedimos que participe en un importante estudio acerca del bienestar y la prevención de enfermedades. Los Centros para Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), la agencia que dirige Medicare, están reuniendo información acerca de sus experiencias en el control y mantenimiento de su salud. Queremos asegurarnos de que reciba el mejor cuidado posible, así que es importante que escuchemos sus experiencias.
Le estamos pidiendo que conteste esta encuesta ya que usted es un beneficiario de Medicare y recientemente asistió a un programa preventivo de salud ofrecido por uno de nuestros socios de este estudio. En la encuesta, le preguntamos acerca de su salud en general, cómo controla su salud y cómo previene enfermedades y lesiones. Esta encuesta es voluntaria, y su participación no afectará ninguno de los beneficios que recibe de Medicare. Mantendremos sus respuestas de manera confidencial.
Los resultados de la encuesta los usará Medicare para comprender cómo los programas comunitarios preventivos de salud influyen en la salud y el bienestar de los beneficiarios de Medicare.
Le agradecemos el tiempo que ha dedicado para participar en la encuesta. De antemano le agradecemos su colaboración. Si tiene alguna pregunta acerca de la encuesta, sírvase llamar al [insert Westat 800 number] o envíe un correo electrónico a [insert Westat email address].
Atentamente,
Erin Colligan, PhD, MPP
Jefe del proyecto CMS
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Dear [NAME]:
A few weeks ago your household was mailed a survey from the Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare. We are gathering information about your experiences managing your health and staying well. We want to make sure that you receive the best possible care so it is important that we hear about your experiences.
Your cooperation is very important. We are enclosing another copy of the survey and ask that you complete it and return it in the enclosed, prepaid envelope.
You are being asked to complete this survey because you are a Medicare beneficiary who recently attended a wellness program that is a partner in this study. In the survey, we ask about your general health, managing your health, and preventing illness and injury. This survey is voluntary, and your participation will not affect your Medicare benefits. Your answers will be kept confidential.
Results from the survey will be used by Medicare to understand how community wellness programs affect the health and wellbeing of Medicare Beneficiaries.
We appreciate your taking the time to participate in our survey. Thank you in advance for your cooperation. If you have any questions about the survey, please call [insert Westat 800 number] or send an email to [insert Westat email address].
Si desea recibir una copia en español de los materiales de esta encuesta, sírvase llamar al [#] o enviar un correo electrónico a [[email protected]].
Sincerely,
Erin Colligan, PhD, MPP
CMS Project Officer
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Estimado(a) [NAME]:
Hace unas semanas le enviamos a su hogar una encuesta de los Centros para Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), la agencia que dirige Medicare. Estamos reuniendo información acerca de sus experiencias en el control y mantenimiento de su salud. Queremos asegurarnos de que reciba el mejor cuidado posible, así que es importante que escuchemos sus experiencias.
Su colaboración es muy importante. Estamos adjuntando otra copia de la encuesta y le pedimos que la conteste y la devuelva en el sobre adjunto con franqueo pagado.
Le estamos pidiendo que conteste esta encuesta ya que usted es un beneficiario de Medicare y recientemente asistió a un programa preventivo de salud ofrecido por uno de nuestros socios de este estudio. En la encuesta, le preguntamos acerca de su salud en general, cómo controla su salud y cómo previene enfermedades y lesiones. Esta encuesta es voluntaria, y su participación no afectará ninguno de los beneficios que recibe de Medicare. Mantendremos sus respuestas de manera confidencial.
Los resultados de la encuesta los usará Medicare para comprender cómo los programas comunitarios preventivos de salud influyen en la salud y el bienestar de los beneficiarios de Medicare.
Le agradecemos el tiempo que ha dedicado para participar en la encuesta. De antemano le agradecemos su colaboración. Si tiene alguna pregunta acerca de la encuesta, sírvase llamar al [insert Westat 800 number] o envíe un correo electrónico a [insert Westat email address].
Atentamente,
Erin Colligan, PhD, MPP
Jefe del proyecto CMS
[Calls will be placed using an Automated Interactive Voice Response (IVR) telephone system]
Hello, we are calling on behalf of the Centers for Medicare and Medicaid Services, the Medicare Agency.
We recently sent you or another adult in your household a Medicare Beneficiary survey about wellness and disease prevention.
If you have already returned your completed survey, thank you very much. If you haven’t, we ask that you complete the survey as soon as possible and return it in the postage-paid envelope we provided. If you have questions about the survey, please call us toll-free at 1-xxx-xxx-xxxx. Thank you very much for your help on this important research study. (This message will repeat.)
[Calls will be placed using an Automated Interactive Voice Response (IVR) telephone system]
Buenos días/Buenas tardes, estamos llamando en nombre de los Centros para Servicios de Medicare y Medicaid, la Agencia Medicare.
Recientemente le enviamos a usted u otro adulto de su hogar una encuesta para beneficiarios de Medicare acerca del bienestar y la prevención de enfermedades.
Si ya nos ha devuelto su encuesta contestada, se lo agradecemos mucho. Si no lo ha hecho, le pedimos que conteste la encuesta lo más pronto posible y que la devuelva en el sobre con franqueo pagado que le enviamos. Si tiene preguntas acerca de la encuesta, sírvase llamarnos a la línea directa y gratuita al 1-xxx-xxx-xxxx. Muchísimas gracias por su colaboración en este importante estudio de investigación. (Se volverá a repetir este mensaje.)
Your Health
These first questions are about your health.
1. In general, would you say your health is
□ Excellent
□ Very good
□ Good
□ Fair
□ Poor
2. Compared to one year ago, how would you rate your health in general now?
□ Much better than one year ago
□ Somewhat better now than one year ago
□ About the same as one year ago
□ Somewhat worse now than one year ago
□ Much worse now than one year ago
3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
a. Vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
c. Lifting or carrying groceries
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
d. Climbing several flights of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
e. Climbing one flight of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
f. Bending, kneeling, or stooping
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
g. Walking more than a mile
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
h. Walking several hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
i. Walking one hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
j. Bathing or dressing yourself
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Were limited in the kind of work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Had difficulty performing the work or other activities (for example, it took extra effort)
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
5. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Did work or activities less carefully than usual
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
□ Not at all
□ Slightly
□ Moderately
□ Quite a bit
□ Extremely
7. How much bodily pain have you had during the past 4 weeks?
□ None
□ Very mild
□ Mild
□ Moderate
□ Severe
□ Very severe
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…
a. Did you feel full of life?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Have you been very nervous?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Have you felt so down in the dumps that nothing could cheer you up?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Have you felt calm and peaceful?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
e. Did you have a lot of energy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
f. Have you felt downhearted and depressed?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
g. Did you feel worn out?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
h. Have you been happy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
i. Did you feel tired?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
11. How TRUE or FALSE is each of the following statements for you?
a. I seem to get sick a little easier than other people
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
b. I am as healthy as anybody I know
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
c. I expect my health to get worse
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
d. My health is excellent
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
12. Which statement best describes your vision (with glasses or contact lenses if you wear them)?
□ I have no trouble seeing
□ I have a little trouble seeing
□ I have a lot of trouble seeing
□ I am blind
13. Which statement best describes your hearing (with a hearing aid if you use one)?
□ I have no trouble hearing
□ I have a little trouble hearing
□ I have a lot of trouble hearing
□ I am deaf
14. How tall are you?
____ feet ____ inches
15. How much do you weigh?
_____ pounds
16. Has a doctor ever told you that you have arthritis?
□ Yes
□ No
17. Other than during pregnancy, has a doctor EVER told you that you have diabetes or sugar diabetes?
□ Yes
□ No
18. Other than during pregnancy, has a doctor EVER told you that you have pre-diabetes or borderline diabetes?
□ Yes
□ No
19. Have you ever smoked cigarettes, cigars, or pipe tobacco?
□ Yes
□ No
20. Do you smoke cigarettes, cigars, or pipe tobacco now?
□ Yes
□ No
21. Have you had a flu shot in the past year?
□ Yes
□ No
The next question is about actions your health care provider may have suggested that you take to improve your health. |
22. In the past 12 months, has a doctor, nurse, or other health care provider suggested you do any of the following. Please mark all that apply.
□ I have not visited a doctor or other health care professional in the past 12 months Go to 23
□ Eat more healthful foods, such as fruits, vegetables, and whole grains
□ Lose or gain weight
□ Get regular exercise appropriate for your ability
□ Improve your balance, such as to help prevent falls
□ Manage health problems like arthritis, diabetes, high blood pressure
□ None of these
The next few questions are about your awareness of and enrollment in wellness programs to help you make a change based on your need. |
Wellness programs are ongoing, organized group meetings or sessions, done online or in person, where the focus is on improving one’s health through knowledge and/or activity. (Do not include diet or fitness programs done on an individual basis.)
23. Besides your wellness program, do you know of any other wellness programs in your community or online to help people like you make these kinds of changes?
□ Yes, in my community
□ Yes, online
□ No
24. Besides your wellness program, are you currently enrolled in any other wellness programs in your community or online to help you make this kind of change?
□ Yes Go to 25
□ No Skip to 26
25. What other kind of wellness program are you currently enrolled in? This includes both community-based and online programs. Please mark all that apply.
□ Eating healthful foods, such as fruits, vegetables, and whole grains
□ Managing your weight
□ Getting regular exercise appropriate for your ability
□ Improving your balance and preventing falls
□ Managing health problems like arthritis, diabetes, high blood pressure, or other conditions
□ Other
Making Health Care Decisions
The next questions are about making health care decisions. Your answers will help Medicare better understand how people use medical services. Please keep in mind that there are no right or wrong answers to these questions. Your opinions and experiences are important to us.
26. How confident are you that you can identify when it is necessary for you to get medical care?
□ Very confident
□ Confident
□ Somewhat confident
□ Not at all confident
27. Do you always, usually, sometimes, or never take a list of all your prescribed medicines to your doctor visits?
□ Always
□ Usually
□ Sometimes
□ Never
□ I don’t take any prescribed medications
Your Beliefs
Please choose the response which fits you best to the following statements:
28. I will be able to achieve most of the goals that I have set for myself.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
29. When facing difficult tasks, I am certain that I will accomplish them.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
30. In general, I think that I can obtain outcomes that are important to me.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
31. I believe I can succeed at almost anything that I set my mind to.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
32. I will be able to successfully overcome many challenges.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
33. I am confident that I can perform effectively on many different tasks.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
34. Compared to other people, I can do most tasks very well.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
35. Even when things are tough, I can perform quite well.
□ Strongly agree
□ Agree
□ Neutral
□ Disagree
□ Strongly Disagree
How You’ve Been Feeling Lately
The next two questions are about how you have been feeling lately.
36. Over the last 2 weeks, how often have you been bothered by any of the following:
a. Little interest or pleasure in doing things?
□ Not at all
□ Several days
□ More than half the days
□ Nearly every day
b. Feeling down, depressed, or hopeless?
□ Not at all
□ Several days
□ More than half the days
□ Nearly every day
Physical Activity
Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation. The following questions ask about the amount and intensity of physical activity you usually do. The intensity of the activity is related to the amount of energy you use to do these activities.
Examples of physical intensity levels:
Intensity level |
Examples |
Light activities: Your heart beats slightly faster than normal. You can talk and sing |
Walking leisurely, stretching, vacuuming or light yard work |
Moderate activities: Your heart beats faster than normal. You can talk but not sing. |
Fast walking, aerobics class, strength training, swimming gently |
Vigorous activities: Your heart rate increases a lot. You can’t talk or your talking is broken up by large breaths. |
Stair machine, jogging or running, tennis, racquetball, or badminton |
37. How physically active are you? Please check one answer for each question.
a. I rarely or never do any physical activities.
□ Yes
□ No
b. I do some light or moderate physical activities, but not every week.
□ Yes
□ No
c. I do some light physical activity every week.
□ Yes
□ No
d. I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week.
□ Yes
□ No
f. I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week.
□ Yes
□ No
g. I do 30 minutes or more a day of moderate physical activities, 5 or more days a week.
□ Yes
□ No
h. I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week.
□ Yes
□ No
i. I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more.
□ Yes
□ No
j. I do activities to improve flexibility, such as stretching or yoga, once a week or more.
□ Yes
□ No
Fall and Balance
38a. A fall is when your body goes to the ground without being pushed. Did you fall in the past 6 months?
□ Yes _________ times
□ No Skip to 39
38b. How many of these falls caused you to limit your regular activities for at least a day or to see a doctor?
_________Falls limiting activity or requiring medical attention
39. In the past 6 months, have you had a problem with balance or walking?
□ Yes
□ No
□ Limited to a bed or wheelchair Skip to 43
40. Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? Some things they might do include:
Suggest that you use a cane or walker
Check your blood pressure lying or standing
Suggest that you do an exercise or physical therapy program
Suggest a vision or hearing testing
□ Yes
□ No
41. Are you afraid of falling?
□ Yes
□ No
Your Confidence in Balance
The next questions are about keeping your balance in different situations. You may have to imagine yourself in these situations if you have not encountered them recently. For each one, choose any number between 0 (no confidence) and 100 (complete confidence) to say how confident you are that you could keep your balance. If you normally use a cane or walker or hold on to someone, answer as if you had that help.
0 10 20 30 40 50 60 70 80 90 100
No Confidence Complete Confidence
42. How confident are you that you can maintain your balance and remain steady when you…
a. Stand on your tiptoes and reach for something above your head?
__________
b. Stand on a chair and reach for something?
__________
c. Are bumped into by people as you walk through the mall?
__________
d. Step onto or off of an escalator while holding onto a railing?
__________
e. Step onto or off of an escalator while holding a package so you cannot hold onto the railing?
__________
f. Walk outside on icy sidewalks?
__________
Medicines
The next few questions are about medicines.
43. Do you ever forget to take your medicine?
□ I don’t take any medicines Skip to 47
□ Yes
□ No
44. Do you ever have problems remembering to take your medicine?
□ Yes
□ No
45. When you feel better, do you sometimes stop taking your medicine?
□ Yes
□ No
46. Sometimes if you feel worse when you take your medicine, do you stop taking it?
□ Yes
□ No
Getting Help From Others
47. People sometimes look to others for companionship, assistance, or other types of support. How often is each of the following kinds of support available to you if you need it?
a. Someone to help you if you were confined to bed?
□ None of the time
□ A little of the time
□ Some of the time
□ Most of the time
□ All of the time
b. Someone to take you to the doctor if you needed it?
□ None of the time
□ A little of the time
□ Some of the time
□ Most of the time
□ All of the time
c. Someone to prepare your meals if you were unable to do it yourself?
□ None of the time
□ A little of the time
□ Some of the time
□ Most of the time
□ All of the time
d. Someone to help with daily chores if you were sick?
□ None of the time
□ A little of the time
□ Some of the time
□ Most of the time
□ All of the time
Demographics
48. What is your sex?
□ Male
□ Female
The next two questions are about Hispanic origin and race. |
49. Are you of Hispanic, Latino, or Spanish origin?
□ Yes
□ No
50. What is your race? Please select one or more.
□ American Indian or Alaska Native
□ Asian
□ Black or African American
□ Native Hawaiian or other Pacific Islander
□ White
51. When were you born? Please provide your date of birth in month/day/year.
___ ___Month
___ ___Day
1 9 ___ ___Year
52. How well do you speak English?
□ Very well
□ Well
□ Not well
□ Not at all
53. What is your current marital status?
□ Married
□ Living as married
□ Divorced
□ Separated
□ Widowed
□ Never married
54. What is the highest grade or level of school that you have completed?
□ 8th grade or less
□ Some high school, but did not graduate
□ High school graduate or GED
□ Some college or 2 year degree
□ 4 year college graduate
□ More than a 4 year college degree
55. Where do you live?
□ House, apartment, condominium, mobile home
□ Assisted living apartment or board care home Skip to 57
□ Other
56. Do you live alone or with others? (One or more categories may be selected)
□ Alone
□ With spouse/significant other
□ With adult children
□ With other relatives
□ With non-relatives
57. What is your current employment status?
□ Employed at a job for pay, full-time
□ Employed at a job for pay, part-time
□ Homemaker, not currently working for pay
□ Not currently employed, retired
□ Not currently employed, not retired
58. What type of health insurance do you currently have? (Check all that apply.)
□ Medicare
□ Medicaid (provided by state governments for low income individuals)
□ A Medicare Supplemental plan
□ A Medicare Advantage plan
□ VA or Tricare
□ Private health insurance (such as through an employer)
□ Other
□ None
59. Do you currently provide care for someone else in your home?
□Yes Go to 60
□No Skip to 61
60. During the past week, how many days did you provide at least some care?
□ No care provided in the last week
□ 1 or 2 days
□ 3 or 4 days
□ 5 or 6 days
□ 7 days (every day)
61. Do you have difficulty getting to places you need to go?
□ No, I can drive, get a ride, take public transportation, or walk
□ Yes, always or almost always
□ Yes, Sometimes
62. Who completed this survey form?
□ Person to whom survey was addressed
□ Family member or relative of person to whom the survey was addressed
□ Friend of person to whom the survey was addressed
□ Professional caregiver of person to whom the survey was addressed
63. Which of the following categories best represents the combined income for all family members in your household for the past 12 months?
□ $11,670 or less
□ $11,671-$15,730
□ $15,731-$19,999
□ $20,000–$29,999
□ $30,000–$39,999
□ $40,000–$49,999
□ $50,000–$79,999
□ $80,000–$99,999
□ $100,000 or more
□ Don’t know
64. As part of this study, we would like obtain information on your use of health services and combine it with your survey responses. It will be very helpful to have information that will help us identify your Medicare records. This information will be used only for our research, and we will not share any information that would identify you outside of this study.
a. Please provide the last four digits of your Social Security number:
___ ___ ___ ___ (last 4 digits of SSN)
b. Please provide your Medicare Health Insurance Claim (HIC) number:
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
65. Date of completing this survey:
___ ___Month
___ ___Day
20 ___ ___Year
Thank you for your time. Please mail the survey using the prepaid addressed envelope enclosed.
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Dear [NAME]:
I am writing to ask you to take part in an important survey about wellness and disease prevention. The Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare, is gathering information about your experiences managing your health and staying well. We want to make sure that you receive the best possible care so it is important that we hear about your experiences.
You are being asked to complete this survey as a follow-up to the survey about wellness that you completed 6 months ago. In this survey, we ask beneficiaries who recently completed a wellness program for updates on their general health and wellness. This survey is voluntary, and your participation will not affect your Medicare benefits. Your answers will be kept confidential.
Results from the survey will be used by Medicare to understand how community wellness programs affect the health and wellbeing of Medicare Beneficiaries.
We appreciate your taking the time to participate in our survey. Thank you in advance for your cooperation. If you have any questions about the survey, please call [insert Westat 800 number] or send an email to [insert Westat email address].
Si desea recibir una copia en español de los materiales de esta encuesta, sírvase llamar al [#] o enviar un correo electrónico a [[email protected]].
Sincerely,
Erin Colligan, PhD, MPP
CMS Project Officer
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Estimado(a) [NAME]:
Por medio de la presente le pedimos que participe en un importante estudio acerca del bienestar y la prevención de enfermedades. Los Centros para Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), la agencia que dirige Medicare, están reuniendo información acerca de sus experiencias en el control y mantenimiento de su salud. Queremos asegurarnos de que reciba el mejor cuidado posible, así que es importante que escuchemos sus experiencias.
Le estamos pidiendo que conteste esta encuesta como continuación a la encuesta del bienestar que contestó hace 6 meses. En esta encuesta, les pedimos a los beneficiarios que acaban de terminar un programa preventivo de salud que nos den una actualización de su salud y bienestar en general. Esta encuesta es voluntaria, y su participación no afectará ninguno de los beneficios que recibe de Medicare. Mantendremos sus respuestas de manera confidencial.
Los resultados de la encuesta los usará Medicare para comprender cómo los programas comunitarios preventivos de salud influyen en la salud y el bienestar de los beneficiarios de Medicare.
Le agradecemos el tiempo que ha dedicado para participar en la encuesta. De antemano le agradecemos su colaboración. Si tiene alguna pregunta acerca de la encuesta, sírvase llamar al [insert Westat 800 number] o envíe un correo electrónico a [insert Westat email address].
Atentamente,
Erin Colligan, PhD, MPP
Jefe del proyecto CMS
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Dear [NAME]:
A few weeks ago your household was mailed a survey from the Centers for Medicare and Medicaid Services (CMS), the agency that runs Medicare. We are gathering information about your experiences managing your health and staying well. We want to make sure that you receive the best possible care so it is important that we hear about your experiences.
Your cooperation is very important. We are enclosing another copy of the survey and ask that you complete it and return it in the enclosed, prepaid envelope.
You are being asked to complete this survey as a follow-up to the survey about wellness that you completed 6 months ago. In this survey, we ask beneficiaries who recently completed a wellness program for updates on their general health and wellness. This survey is voluntary, and your participation will not affect your Medicare benefits. Your answers will be kept confidential.
Results from the survey will be used by Medicare to understand how community wellness programs affect the health and wellbeing of Medicare Beneficiaries.
We appreciate your taking the time to participate in our survey. Thank you in advance for your cooperation. If you have any questions about the survey, please call [insert Westat 800 number] or send an email to [insert Westat email address].
Si desea recibir una copia en español de los materiales de esta encuesta, sírvase llamar al [#] o enviar un correo electrónico a [[email protected]].
Sincerely,
Erin Colligan, PhD, MPP
CMS Project Officer
[CMS LETTERHEAD]
[NAME]
[ADDRESS 1]
[ADDRESS 2]
[CITY], [STATE] [ZIP]
Estimado(a) [NAME]:
Hace unas semanas le enviamos a su hogar una encuesta de los Centros para Servicios de Medicare y Medicaid (CMS, por sus siglas en inglés), la agencia que dirige Medicare. Estamos reuniendo información acerca de sus experiencias en el control y mantenimiento de su salud. Queremos asegurarnos de que reciba el mejor cuidado posible, así que es importante que escuchemos sus experiencias.
Su colaboración es muy importante. Estamos adjuntando otra copia de la encuesta y le pedimos que la conteste y la devuelva en el sobre adjunto con franqueo pagado.
Le estamos pidiendo que conteste esta encuesta como continuación a la encuesta del bienestar que contestó hace 6 meses. En esta encuesta, les pedimos a los beneficiarios que acaban de terminar un programa preventivo de salud que nos den una actualización de su salud y bienestar en general. Esta encuesta es voluntaria, y su participación no afectará ninguno de los beneficios que recibe de Medicare. Mantendremos sus respuestas de manera confidencial.
Los resultados de la encuesta los usará Medicare para comprender cómo los programas comunitarios preventivos de salud influyen en la salud y el bienestar de los beneficiarios de Medicare.
Le agradecemos el tiempo que ha dedicado para participar en la encuesta. De antemano le agradecemos su colaboración. Si tiene alguna pregunta acerca de la encuesta, sírvase llamar al [insert Westat 800 number] o envíe un correo electrónico a [insert Westat email address].
Atentamente,
Erin Colligan, PhD, MPP
Jefe del proyecto CMS
Your Health
These first questions are about your health.
1. In general, would you say your health is
□ Excellent
□ Very good
□ Good
□ Fair
□ Poor
2. Compared to one year ago, how would you rate your health in general now?
□ Much better than one year ago
□ Somewhat better now than one year ago
□ About the same as one year ago
□ Somewhat worse now than one year ago
□ Much worse now than one year ago
3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
a. Vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
c. Lifting or carrying groceries
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
d. Climbing several flights of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
e. Climbing one flight of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
f. Bending, kneeling, or stooping
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
g. Walking more than a mile
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
h. Walking several hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
i. Walking one hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
j. Bathing or dressing yourself
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Were limited in the kind of work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Had difficulty performing the work or other activities (for example, it took extra effort
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
5. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Did work or activities less carefully than usual
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
□ Not at all
□ Slightly
□ Moderately
□ Quite a bit
□ Extremely
7. How much bodily pain have you had during the past 4 weeks?
□ None
□ Very mild
□ Mild
□ Moderate
□ Severe
□ Very severe
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…
a. Did you feel full of life?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Have you been very nervous?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Have you felt so down in the dumps that nothing could cheer you up?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Have you felt calm and peaceful?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
e. Did you have a lot of energy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
f. Have you felt downhearted and depressed?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
g. Did you feel worn out?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
h. Have you been happy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
i. Did you feel tired?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
11. How TRUE or FALSE is each of the following statements for you?
a. I seem to get sick a little easier than other people
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
b. I am as healthy as anybody I know
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
c. I expect my health to get worse
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
d. My health is excellent
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
Physical Activity
Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation. The following questions ask about the amount and intensity of physical activity you usually do. The intensity of the activity is related to the amount of energy you use to do these activities.
Examples of physical intensity levels:
Intensity level |
Examples |
Light activities: Your heart beats slightly faster than normal. You can talk and sing |
Walking leisurely, stretching, vacuuming or light yard work |
Moderate activities: Your heart beats faster than normal. You can talk but not sing. |
Fast walking, aerobics class, strength training, swimming gently |
Vigorous activities: Your heart rate increases a lot. You can’t talk or your talking is broken up by large breaths. |
Stair machine, jogging or running, tennis, racquetball, or badminton |
12. How physically active are you? Please check one answer for each question.
a. I rarely or never do any physical activities.
□ Yes
□ No
b. I do some light or moderate physical activities, but not every week.
□ Yes
□ No
c. I do some light physical activity every week.
□ Yes
□ No
d. I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week.
□ Yes
□ No
e. I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week.
□ Yes
□ No
f. I do 30 minutes or more a day of moderate physical activities, 5 or more days a week.
□ Yes
□ No
g. I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week.
□ Yes
□ No
h. I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more.
□ Yes
□ No
i. I do activities to improve flexibility, such as stretching or yoga, once a week or more.
□ Yes
□ No
Fall
13. A fall is when your body goes to the ground without being pushed. Did you fall in the past 6 months?
□ Yes _________ times
□ No Skip to 15
14. How many of these falls caused you to limit your regular activities for at least a day or to see a doctor?
__________Falls limiting activity or requiring medical attention
15. In the past 6 months, have you had a problem with balance or walking?
□ Yes
□ No
□ Limited to a bed or wheelchair Skip to 18
16. Are you afraid of falling?
□ Yes
□ No
Your Confidence in Balance
The next questions are about keeping your balance in different situations. You may have to imagine yourself in these situations if you have not encountered them recently. For each one, choose any number between 0 (no confidence) and 100 (complete confidence) to say how confident you are that you could keep your balance. If you normally use a cane or walker or hold on to someone, answer as if you had that help.
0 10 20 30 40 50 60 70 80 90 100
No Confidence Complete Confidence
17. How confident are you that you can maintain your balance and remain steady when you…
a. Stand on your tiptoes and reach for something above your head?
__________
b. Stand on a chair and reach for something?
__________
c. Are bumped into by people as you walk through the mall?
__________
d. Step onto or off of an escalator while holding onto a railing?
__________
e. Step onto or off of an escalator while holding a package so you cannot hold onto the railing?
__________
f. Walk outside on icy sidewalks?
__________
Medicines
The next few questions are about medicines.
18. Do you ever forget to take your medicine?
□ I don’t take any medicines Skip to 22
□ Yes
□ No
19. Do you ever have problems remembering to take your medicine?
□ Yes
□ No
20. When you feel better, do you sometimes stop taking your medicine?
□ Yes
□ No
21. Sometimes if you feel worse when you take your medicine, do you stop taking it?
□ Yes
□ No
Program Participation
22. Our records show that you participated in ____________________________________. How many of the program sessions or meetings did you participate in?
□ All sessions or meetings
□ Most of the sessions or meetings
□ Half of the sessions or meetings
□ Fewer than half of the sessions or meetings
Wellness programs are ongoing, organized group meetings or sessions, done online or in person, where the focus is on improving one’s health through knowledge and/or activity. (Do not include diet or fitness programs done on an individual basis.)
23a. Besides the above program, have you participated in any other wellness programs, either in your community or online, to improve your health in the past six months?
□ Yes , in my community Go to 23b
□ Yes, online Go to 23b
□ No Skip to 24
23b. What other kind of wellness programs did you participate in in the past six months? Check all that apply.
□ Eating healthful foods, such as fruits, vegetables, and whole grains
□ Managing your weight
□ Getting regular exercise appropriate for your ability
□ Improving your balance and preventing falls
□ Managing health problems like arthritis, diabetes, high blood pressure, or other conditions
□ None of the above
□ Other, Specify:
__________________________________________________________________________
24. How much would you be willing to pay in total for the program that you enrolled in? $_________
25. What would you say was the best thing about the program?
26. Date of filling out this survey:
___ ___/___ ___/20___ ___
Month Day Year
27. Are you still participating in _____________________________(name & location of program)
□ Yes [Stop here. Thank you for your time. Please mail the survey using the prepaid addressed envelope enclosed.]
□ No [Go to Question 28]
28. Did you stop participating in the program when it was over or before it was over?
□ I stopped participating in the program when it was over [Stop here. Thank you for your time. Please mail the survey using the prepaid addressed envelope enclosed.]
□ I stopped participating in the program before it was over [Go to Question 29]
29. Did you decide to leave the program because of your ill health?
□ Yes
□ No
30a. Did you decide to leave the program because it did not meet your health needs?
□ Yes [Go to 30b]
□ No [Skip to 31]
30b. In what ways did the program fail to meet your health needs? [Please specify in the space below.]
31. Below is a list of possible reasons why someone might leave the program. For each, please select how important it was in YOUR decision to leave the program.
-
Possible reasons why someone might leave the program
Very important in my decision
Somewhat important in my decision
Not at all important in my decision
The instructor was not helpful
□
□
□
I did not learn anything new
□
□
□
I did not achieve the results I expected
□
□
□
Parking was a problem
□
□
□
The program location was too far
□
□
□
Transportation was a problem
□
□
□
The program hours were not convenient to me
□
□
□
The program was not offered in my main spoken language
□
□
□
Not enough people in the program were the same gender as myself
□
□
□
Not enough people in the program were in my age group
□
□
□
The instructor was not in my age group
□
□
□
The instructor was not the same gender as myself
□
□
□
The program cost was too high
□
□
□
32. Please use the space below to describe any other reasons you had for deciding to leave the program.
33. What would it take for you to return to the program? Please list anything that comes to mind when thinking about what it would take for you to return to the program.
Thank you for your time. Please mail the survey using the prepaid addressed envelope enclosed.
Your Health
These first questions are about your health.
1. In general, would you say your health is
□ Excellent
□ Very good
□ Good
□ Fair
□ Poor
2. Compared to one year ago, how would you rate your health in general now?
□ Much better than one year ago
□ Somewhat better now than one year ago
□ About the same as one year ago
□ Somewhat worse now than one year ago
□ Much worse now than one year ago
3. The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
a. Vigorous activities, such as running, lifting heavy objects, or participating in strenuous sports
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
b. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
c. Lifting or carrying groceries
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
d. Climbing several flights of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
e. Climbing one flight of stairs
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
f. Bending, kneeling, or stooping
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
g. Walking more than a mile
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
h. Walking several hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
i. Walking one hundred yards
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
j. Bathing or dressing yourself
□ Yes, limited a lot
□ Yes, limited a little
□ No, not limited at all
4. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Were limited in the kind of work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Had difficulty performing the work or other activities (for example, it took extra effort
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
5. During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
a. Cut down on the amount of time you spent on work or other activities
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Accomplished less than you would like
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Did work or activities less carefully than usual
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
6. During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?
□ Not at all
□ Slightly
□ Moderately
□ Quite a bit
□ Extremely
7. How much bodily pain have you had during the past 4 weeks?
□ None
□ Very mild
□ Mild
□ Moderate
□ Severe
□ Very severe
8. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?
□ Not at all
□ A little bit
□ Moderately
□ Quite a bit
□ Extremely
9. These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
How much of the time during the past 4 weeks…
a. Did you feel full of life?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Have you been very nervous?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
c. Have you felt so down in the dumps that nothing could cheer you up?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Have you felt calm and peaceful?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
e. Did you have a lot of energy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
f. Have you felt downhearted and depressed?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
g. Did you feel worn out?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
h. Have you been happy?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
i. Did you feel tired?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?
□ All of the time
□ Most of the time
□ Some of the time
□ A little of the time
□ None of the time
11. How TRUE or FALSE is each of the following statements for you?
a. I seem to get sick a little easier than other people
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
b. I am as healthy as anybody I know
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
c. I expect my health to get worse
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
d. My health is excellent
□ Definitely true
□ Mostly true
□ Don’t know
□ Mostly false
□ Definitely false
Physical Activity
Physical activities are activities where you move and increase your heart rate above its resting rate, whether you do them for pleasure, work, or transportation. The following questions ask about the amount and intensity of physical activity you usually do. The intensity of the activity is related to the amount of energy you use to do these activities.
Examples of physical intensity levels:
Intensity level |
Examples |
Light activities: Your heart beats slightly faster than normal. You can talk and sing |
Walking leisurely, stretching, vacuuming or light yard work |
Moderate activities: Your heart beats faster than normal. You can talk but not sing. |
Fast walking, aerobics class, strength training, swimming gently |
Vigorous activities: Your heart rate increases a lot. You can’t talk or your talking is broken up by large breaths. |
Stair machine, jogging or running, tennis, racquetball, or badminton |
12. How physically active are you? Please check one answer for each question.
a. I rarely or never do any physical activities.
□ Yes
□ No
b. I do some light or moderate physical activities, but not every week.
□ Yes
□ No
c. I do some light physical activity every week.
□ Yes
□ No
d. I do moderate physical activities every week, but less than 30 minutes a day or 5 days a week.
□ Yes
□ No
e. I do vigorous physical activities every week, but less than 20 minutes a day or 3 days a week.
□ Yes
□ No
f. I do 30 minutes or more a day of moderate physical activities, 5 or more days a week.
□ Yes
□ No
g. I do 20 minutes or more a day of vigorous physical activities, 3 or more days a week.
□ Yes
□ No
h. I do activities to increase muscle strength, such as lifting weights or calisthenics, once a week or more.
□ Yes
□ No
i. I do activities to improve flexibility, such as stretching or yoga, once a week or more.
□ Yes
□ No
Fall
13. A fall is when your body goes to the ground without being pushed. Did you fall in the past 6 months?
□ Yes _________ times
□ No Skip to 15
14. How many of these falls caused you to limit your regular activities for at least a day or to see a doctor?
__________Falls limiting activity or requiring medical attention
15. In the past 6 months, have you had a problem with balance or walking?
□ Yes
□ No
□ Limited to a bed or wheelchair Skip to 18
16. Are you afraid of falling?
□ Yes
□ No
Your Confidence in Balance
The next questions are about keeping your balance in different situations. You may have to imagine yourself in these situations if you have not encountered them recently. For each one, choose any number between 0 (no confidence) and 100 (complete confidence) to say how confident you are that you could keep your balance. If you normally use a cane or walker or hold on to someone, answer as if you had that help.
0 10 20 30 40 50 60 70 80 90 100
No Confidence Complete Confidence
17. How confident are you that you can maintain your balance and remain steady when you…
a. Stand on your tiptoes and reach for something above your head?
__________
b. Stand on a chair and reach for something?
__________
c. Are bumped into by people as you walk through the mall?
__________
d. Step onto or off of an escalator while holding onto a railing?
__________
e. Step onto or off of an escalator while holding a package so you cannot hold onto the railing?
__________
f. Walk outside on icy sidewalks?
__________
Medicines
The next few questions are about medicines.
18. Do you ever forget to take your medicine?
□ I don’t take any medicines Skip to 22
□ Yes
□ No
19. Do you ever have problems remembering to take your medicine?
□ Yes
□ No
20. When you feel better, do you sometimes stop taking your medicine?
□ Yes
□ No
21. Sometimes if you feel worse when you take your medicine, do you stop taking it?
□ Yes
□ No
Program Participation
22. Our records show that you participated in
__________________________________.
How many of the program sessions or meetings did you participate in?
□ All sessions or meetings
□ Most of the sessions or meetings
□ Half of the sessions or meetings
□ Fewer than half of the sessions or meetings
Wellness programs are ongoing, organized group meetings or sessions, done online or in person, where the focus is on improving one’s health through knowledge and/or activity. (Do not include diet or fitness programs done on an individual basis.)
23a. Besides the above program, have you participated in any other wellness programs, either in your community or online, to improve your health in the past six months?
□ Yes , in my community Go to 23b
□ Yes, online Go to 23b
□ No Skip to 24
23b. What other kind of wellness programs did you participate in in the past six months? Check all that apply.
□ Eating healthful foods, such as fruits, vegetables, and whole grains
□ Managing your weight
□ Getting regular exercise appropriate for your ability
□ Improving your balance and preventing falls
□ Managing health problems like arthritis, diabetes, high blood pressure, or other conditions
□ None of the above
□ Other, Specify:
___________________________________
24. Date of completing this survey:
___ ___Month
___ ___Day
20 ___ ___Year
Thank you for your time. Please mail the survey using the prepaid addressed envelope enclosed.
Version: 8/12/2014
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | Part A, Attachment 3 |
| Subject | Wellness Program Participant Surveys |
| Author | Westat |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |
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