STEP Pre Survey

Form Approved

OMB No. 0990-0379

Exp. Date 09/30/2020

Pre-Survey

Date: June 4, 2019 Location: Georges Creek Library

1. How would you rate your overall health? (circle one)

1 – Excellent 2 – Very Good 3 – Good 4 – Fair 5 – Poor

2. Do you suffer from “chronic” pain – meaning pain that lasts longer than a regular head ache or tooth ache?

1 - Yes 2 – No 3 – Sometimes

3. Do opioids, either prescriptions (hydrocodone, oxycodone, codeine, etc.) or illicit (heroin), affect you or someone you love?

1 - Yes 2 - No 3 – Sometimes 4 – They have in the past

If you circled yes: 1 - Family member(s) 2 - Friend(s) 3 - Self

4. Do you practice Yoga?

1. - I currently do 2- I have in the past 3- This is my first time

5. Do you believe Yoga can help reduce pain? 1- Yes 2 – No

6. Do you believe Yoga can reduce stress? 1- Yes 2 – No

7. Have you ever practiced breathing exercise/mindfulness/or meditation?

1. – Yes 2 - No

8. What was the main reason for you to sign-up for STEP Yoga?

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9. What do you hope to learn from participating in STEP Yoga?

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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 0990-0379. The time required to complete this information collection is estimated to average 5 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete 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