PACT: Veteran's Health and Well-Being

Project ID: XXXXX Veterans’ Health and Wellbeing Survey

Veterans’ Health and Wellbeing Survey

OMB 2900-xxxx
Estimated Time Burden: 30 min.

The Paperwork Reduction Act of 1999: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1999. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 30 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve continuity of prescription medical management services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Month Day Year

What is today’s date?

To start off, please think about your experiences with your health and health care. Indicate how often the following statements are true for you.

	Almost Never True	Rarely True	Usually True	Almost Always True
It is very important that I treat my health as my top priority	01	02	03	04
I always know what steps to take when I have a health problem	01	02	03	04
I always know where to look for information before making decisions about my health	01	02	03	04
It is very easy for me to make changes to my daily life to improve my health	01	02	03	04
It is very easy for me to follow my doctor’s instructions	01	02	03	04
I always attend all of my doctors’ appointments	01	02	03	04

These next questions ask you about symptoms that you may or may not have experienced within the last 4 weeks. Have you had any…

	Not at All	A Little Bit	Moderately	Quite a Bit	Extreme
Shortness of breath?	01	02	03	04	05
Chest pain?	01	02	03	04	05
Other pain? (Including head, neck, arm, hand, back, belly, hip, knee, foot/ankle pain)	01	02	03	04	05
Muscle weakness?	01	02	03	04	05
Dizziness or feeling light-headed?	01	02	03	04	05
Balance problems?	01	02	03	04	05
Incontinence (not being able to control bladder or bowels)?	01	02	03	04	05
Problems with your eyesight?	01	02	03	04	05
Problems with memory or thinking?	01	02	03	04	05
Problems with your hearing?	01	02	03	04	05

Each item below is a belief statement about your medical condition with which you may agree or disagree. Beside each statement is a scale which ranges from strongly disagree to strongly agree. For each item, we would like you to mark the checkbox that represents the extent to which you agree or disagree with that statement. Please make sure that you answer every item and that you mark only one box per item. This is a measure of your personal beliefs; there are no right or wrong answers.

	Strongly Disagree	Mostly Disagree	Disagree	Agree	Mostly Agree	Strongly Agree
If I get sick, it is my own behavior which determines how soon l get well again.	01	02	03	04	05	06
No matter what I do, if I am going to get sick I will get sick.	01	02	03	04	05	06
Having regular contact with my physician is the best way for me to avoid illness.	01	02	03	04	05	06
Most things that affect my health happen by accident.	01	02	03	04	05	06
Whenever I don't feel well, I should con­sult a medically trained professional.	01	02	03	04	05	06
l am in control of my health.	01	02	03	04	05	06
Luck plays a big part in determining how soon I will recover from an illness.	01	02	03	04	05	06
Health professionals control my health.	01	02	03	04	05	06
My good health is largely a matter of good fortune.	01	02	03	04	05	06
The main thing that affects my health is what I myself do.	01	02	03	04	05	06
If I take care of myself, I can avoid illness.	01	02	03	04	05	06
When I recover from an illness, it's usually because other people (for example, doctors, nurses, family, friends) have been taking good care of me.	01	02	03	04	05	06
No matter what I do I'm likely to get sick.	01	02	03	04	05	06
If it's meant to be, I will stay healthy.	01	02	03	04	05	06
If I take the right actions, I can stay healthy.	01	02	03	04	05	06
Regarding my health, I can only do what my doctor tells me to do.	01	02	03	04	05	06

Please think about some of the things that we all need to do as part of our daily lives. We would like to know if you can do these activities without any help at all, or if because of your health limitations you need some help to do them, or if you can’t do them at all.

1. Can you use the telephone…

☐01 without help, including looking up numbers and dialing

☐02 with some help (can answer phone or dial operator in an emergency, but need a special phone or

help in getting the number or dialing)

☐03 are you completely unable to use the telephone?

2. Can you get to places out of walking distance...

☐01 without help (drive your own car, or travel alone on buses, or taxis)

☐02 with some help (need someone to help you or go with you when traveling)

☐03 are you unable to travel unless emergency arrangements are made for a specialized vehicle like

an ambulance?

3. Can you go shopping for groceries or clothes…

☐ 01 without help (taking care of all shopping needs yourself, assuming you had transportation)

☐02 with some help (need someone to go with you on all shopping trips)

☐ 03 are you completely unable to do any shopping?

4. Can you prepare your own meals...

☐01 without help (plan and cook full meals yourself)

☐02 with some help (can prepare some things but unable to cook full meals yourself)

☐03 are you completely unable to prepare any meals?

5. Can you do your housework ...

☐01 without help (can clean floors, etc.)

☐02 with some help (can do light housework but need help with heavy work)

☐03 are you completely unable to do any housework?

6. Can you take your own medicine...

☐01 without help (in the right doses at the right time);

☐02 with some help (able to take medicine if someone prepares it for you and/or reminds you to

take it)

☐03 are you completely unable to take your medicines?

7. Can you handle your own money...

☐01 without help (write checks, pay bills, etc.)

☐02 with some help (manage day-to-day buying but need help with managing your checkbook and

paying your bills)

☐03 are you completely unable to handle money?

8. Can you eat...

☐01 without help (able to feed yourself completely)

☐02 with some help (need help with cutting, etc.)

☐03 are you completely unable to feed yourself?

9. Can you dress and undress yourself...

☐01 without help (able to pick out clothes, dress and undress yourself)

☐02 with some help

☐03 are you completely unable to dress and undress yourself?

10. Can you take care of your own appearance, for example combing your hair and (for men)

shaving…

☐01 without help

☐02 with some help

☐03 are you completely unable to maintain your appearance yourself?

11. Can you walk...

☐01 without help (except from a cane)

☐02 with some help from a person or with the use of a walker, or crutches, etc.

☐03 are you completely unable to walk?

12. Can you get in and out of bed...

☐01 without any help or aids

☐02 with some help (either from a person or with the aid of some device)

☐03 are you totally dependent on someone else to lift you?

13. Can you take a bath or shower...

☐01 without help

☐02 with some help (need help getting in and out of the tub, or need special attachments on the tub)

☐03 are you completely unable to bathe yourself?

These next questions ask you about the amount of help that you may receive from friends and family.

	Yes	No
Are you currently married or living with a partner?	01	00
Do you have a family member or friend who gets involved with your health care?	01	00

	Hardly Ever	Some of the Time	Often
How often do you feel that you lack companionship?	01	02	03
How often do you feel left out?	01	02	03
How often do you feel isolated from others?	01	02	03

The following questions ask about your ability to overcome challenges in your life. Please make sure that you answer every item and that you mark only one box per item.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I tend to bounce back quickly after hard times.	01	02	03	04	05
I have a hard time making it through stressful events.	01	02	03	04	05
It does not take me long to recover from a stressful event.	01	02	03	04	05
It is hard for me to snap back when something bad happens.	01	02	03	04	05
I usually come through difficult times with little trouble.	01	02	03	04	05
I tend to take a long time to get over set-backs in my life.	01	02	03	04	05

	Not like me at all	Not much like me	Somewhat like me	Mostly like me	Very much like me
New ideas and projects sometimes distract me from previous ones.	01	02	03	04	05
Setbacks don’t discourage me.	01	02	03	04	05
I have been obsessed with a certain idea or project for a short time but later lost interest.	01	02	03	04	05
I am a hard worker.	01	02	03	04	05
I often set a goal but later choose to pursue a different one.	01	02	03	04	05
I have difficulty maintaining my focus on projects that take more than a few months to complete.	01	02	03	04	05
I finish whatever I begin.	01	02	03	04	05
I am diligent.	01	02	03	04	05

The following questions concern the use of prescription medication and food eaten in your household in the last 12 months and whether you were able to afford medication and food that you need. Please make sure that you answer every item and that you mark only one box per item.

In the past 12 months…	Yes	No	Not taking Prescribed Medicine
…was there any time when you needed prescription medicines but didn't get them because you couldn't afford it?	01	00	999
…did you skip medication doses to save money?	01	00	999
…did you take less medicine to save money?	01	00	999
…did you delay filling a prescription to save money?	01	00	999
…did you ever eat less than you felt you should because there wasn't enough money for food?	01	00
…were you ever hungry but didn't eat because there wasn't enough money for food?	01	00
…did your household ever cut the size of your meals or skip meals because there wasn't enough money for food?	01	00

If YES to any of the last 3 questions about food, how often did this happen?

☐00 Only 1 or 2 months

☐01 Some months but not every month

☐02 Almost every month

☐999 Not applicable (answered “No” to all previous questions about food).

These next questions are about where you typically receive your medical care.

	Mostly at the VA	Mostly outside the VA	About half in VA, half outside VA	Nowhere
Where do you normally receive your medical care?	01	02	03	04

		0 visits	1-3 visits	4-6 visits	7+ visits
How many times in the past 12 months did you visit a non-VA emergency room?		01	02	03	04
How many times in the past 12 months were you admitted for an inpatient stay to a non-VA hospital?		01	02	03	04

Within the past 12 months, have you missed an appointment or been unable to obtain needed health care because of problems with your transportation to the VA?

☐01   Yes

☐00    No  

The next few questions are about your experiences with VA health care.

Please indicate how much you agree or disagree with the statement below.	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I trust VA to fulfill our country’s commitment to veterans.	01	02	03	04	05

Consider all your recent experiences with VA (which may have included healthcare, benefits programs, or memorial services).  Please tell us how you feel about the following statement:	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
I got the service I needed.	01	02	03	04	05
It was easy to get what I needed.	01	02	03	04	05
I felt like a valued customer.	01	02	03	04	05

In the last 12 months…	Never True	Sometimes True	Often True
…the food that we bought just didn’t last, and we didn’t have money to get more.	01	02	03
…we couldn’t afford to eat balanced meals.	01	02	03

These next questions ask for your views about your health. This information will help keep track of how you feel and how well you are able to do your usual activities. If you are unsure how to answer a question, please give the best answer you can.

1. In general, would you say your health is:

☐05 Excellent

☐04 Very good

☐03 Good

☐02 Fair

☐01 Poor

Over the past two weeks, how often have you been bothered with any of the following symptoms?	Not at All	Several Days	More Than Half the Days	Nearly Every Day
Little interest or pleasure in doing things	00	01	02	03
Feeling down, depressed or hopeless	00	01	02	03

The following questions are about your life in general.  Please make sure that you answer every item and that you mark only one box per item.

	Strongly Disagree	Disagree	Neutral	Agree	Strongly Agree
My life is organized.	01	02	03	04	05
My life is unstable.	01	02	03	04	05
My routine is the same from week to week.	01	02	03	04	05
My daily activities from week to week are unpredictable.	01	02	03	04	05
Keeping a schedule is difficult for me.	01	02	03	04	05
I do not like to make appointments too far in advance because I do not know what might come up.	01	02	03	04	05

If you needed it, how often is someone available…	None of the time	A little of the time	Some of the time	Most of the time	All of the time
…to help you if you were confined to bed	01	02	03	04	05
…to take you to the doctor if you need it	01	02	03	04	05
…to prepare your meals if you are unable to do it yourself	01	02	03	04	05
…to help with daily chores if you were sick	01	02	03	04	05
…to have a good time with	01	02	03	04	05
…to turn to for suggestions about how to deal with a personal problem	01	02	03	04	05
…who understands your problems	01	02	03	04	05
…to love and make you feel wanted	01	02	03	04	05

These next questions ask about your usual sleep habits during the past 7 days.

	Not at all	A little bit	Somewhat	Quite a bit	Very Much
My sleep was restless.	01	02	03	04	05
I was satisfied with my sleep.	01	02	03	04	05
My sleep was refreshing.	01	02	03	04	05
I had difficulty falling asleep.	01	02	03	04	05

	Never	Rarely	Sometimes	Often	Always
I had trouble staying asleep.	01	02	03	04	05
I had trouble sleeping.	01	02	03	04	05
I got enough sleep.	01	02	03	04	05

	Very poor	Poor	Fair	Good	Very good
My sleep quality was...	01	02	03	04	05

These next 3 questions are about cigarette smoking.

Do you currently smoke tobacco…

☐02 On a daily basis

☐01 Less than daily

☐00 Not at all

Have you smoked tobacco daily in the past?

☐01 Yes

☐00 No

If you smoked tobacco in the past, did you smoke tobacco…

☐02 On a daily basis

☐01 Less than daily

☐00 Not at all

We would like to ask you a few questions about some things that may have happened to you in the past 12 months.

During the past 12 months did...	Yes	No
. ...you experience an illness or injury (get sick or get hurt) that required staying overnight or longer in a hospital (not a nursing home)?	01	00
...you experience an illness or injury (get sick or get hurt) that kept you from your usual activities (work, housework) for a week or more?	01	00
... you get a divorce?	01	00
…your spouse or significant other die?	01	00
...any of your children die?	01	00
...your spouse/child or other household member leave the home?	01	00
...a close family member or friend experience a serious illness or injury?	01	00
...a very close friend die?	01	00
...a close family member or friend experience a serious illness or injury?	01	00
...you or a family member have any legal trouble (trouble with the law)?	01	00
...you retire from work at your main job?	01	00
...your financial situation improve considerably?	01	00
...your financial situation get considerably worse?	01	00
...you move?	01	00

These last few questions are about your education, employment and economic situation.

What is the highest level of education that you have completed?

☐01 Grade school/junior high

☐02 Some high school

☐03 High school graduate or equivalent (GED)

☐04 Trade/technical/vocational school

☐05 Some college credit but no degree

☐06 Associate's degree (AA or AS)

☐07 Bachelor's degree (BA or BS)

☐08 Post graduate work or graduate degree

Which of the following best describes your current work status? Check all that apply.

☐01 Working Full Time

☐02 Working Part Time

☐03 Unemployed, searching for work

☐04 Unemployed, not searching for work

☐05 Retired

☐06 Disabled

☐07 Student

Which one of the following statements best describes your own personal economic situation?

☐01 I am in good shape. I am able to save and plan for the future.

☐02 I am okay. I am saving a little and I am able to provide for my needs.

☐03 I am barely getting by. I have to budget carefully and I am not able to plan for the future.

☐04 I am falling behind. I have to use savings or go further into debt to pay my bills.

☐05 I am in serious financial trouble, and can't quite see how I am going to make it.

Please mark the answer that best represents your response.	Not at all	A little bit	Somewhat	Quite a bit	Extremely
How confident are you filling out medical forms by yourself?	01	02	03	04	05

Did someone help you to complete this survey? ☐01 Yes ☐00 No

Thank you for participating in this study!

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