OMB No. 0915-xxxx
Expiration Date:
Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.
1. How old were you on your last birthday?
years old
2. Are you Hispanic or Latina? (please check one)
No, I am not Hispanic or Latina
Yes, I am Hispanic or Latina
3. Which one or more of the following would you say is your race? (please check all that apply)
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or other Pacific Islander
4. What is the highest level of education you have completed? (please check one)
Elementary school (grades 1 through 8)
Some high school (grades 9 through 11)
High school graduate or GED
Some college, technical or trade school
Associate degree (2-year)
College graduate (4-year)
Graduate degree (e.g., Masters, Ph.D., J.D., M.D.)
5. What kind of health insurance do you have? (please check one)
Private insurance (through a job, family member)
Public (government) insurance like Medicare or Medicaid
I do not have any health insurance.
I do not know.
6. How do you describe your health in general? (please check one)
Excellent
Very good
Good
Fair
Poor
7. During the past 30 days, how many days did poor physical or mental health keep you from doing most of your usual activities (please check one)
I was able to do my usual activities all 30 days
1–2 days
3–7 days
8–14 days
15 or more days
8. Do you consider yourself to be: (please check one)
Very underweight
Slightly underweight
Healthy weight
Slightly overweight
Very overweight
9. How strongly do you agree or disagree with the following statements? (please check one response for each statement)
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Strongly Disagree |
Moderately Disagree |
Disagree |
Agree |
Moderately Agree |
Strongly Agree |
a. I am responsible for my health. |
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b. If I take care of myself, I can avoid getting sick. |
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c. Good health is mostly due to luck. |
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d. Doing what my doctor tells me to will make me well. |
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e. There are so many strange diseases around that you never know how or when you might get one. |
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f. When people get sick it is because they are careless. |
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10. Thinking about BEFORE you saw your health care provider
today, which of the following statements would you say is most
true?
(please check one)
I was thinking about making changes sometime soon in the amount of physical activity that I do every day.
I was thinking about making some changes during the next month (30 days) in the amount of physical activity I do every day.
I recently started to make changes in the amount of physical activity I do every day.
I have been doing a lot of physical activity every day.
I hadn’t been thinking about physical activity.
11. Thinking about BEFORE you saw your health care provider
today, which of the following statements would you say is most
true?
(please check one)
I was thinking about making changes sometime soon in the types and/or the amount of food I eat.
I was thinking about making some changes in the types and/or the amount of food I eat in the next month (30 days).
I recently started to make changes in the types and/or the amount of food I eat.
I try to eat healthy foods in the right amount every day.
I hadn’t been thinking about healthy eating.
12. BEFORE you came to see your health care provider today, did you want to talk to her/him about healthy eating? (please check one)
Yes
No
13. BEFORE you came to see your health care provider today, did you want to talk to her/him about physical activity? (please check one)
Yes
No
14. Before today, had you ever heard of or seen “My Bright
Future: Physical Activity and Healthy Eating Guide” and Tip
Sheets?
(please check one)
Yes
No
I don’t know
15. Who was the MAIN health care provider who talked to you about
physical activity and healthy eating during your visit
today?
(please check one)
Doctor
Nurse
Nurse Practitioner
Physician’s Assistant
Other (e.g., Health Educator)
16. Was this health care provider female or male? (please check one)
Female
Male
17. Which of the following did you do during this visit? If done, how helpful do you think it will be to your health? (please check yes or no in the first column, and if you check yes, indicate how helpful it was in the columns that follow)
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Did this |
If you checked yes, how helpful was it? |
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Not at all helpful |
Not |
Helpful |
Very |
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a. Before seeing my health care provider, I answered the physical activity questions. |
No Yes |
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b. Before seeing my health care provider, I answered the healthy eating questions. |
No Yes |
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c. My health care provider and I talked about my answers to the healthy eating questions. |
No Yes |
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d. My health care provider and I talked about the foods I eat
and how much |
No Yes |
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e. My health care provider and I talked about my answers to the physical activity questions. |
No Yes |
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f. My health care provider and I talked about what sorts of
physical activity |
No Yes |
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g. I found out whether I was getting enough physical activity every day. |
No Yes |
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h. I was told what my body mass index (BMI) is and what it means. |
No Yes |
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i. My health care provider suggested what I could do to eat healthier. |
No Yes |
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j. My health care provider suggested ways I could become more physically active. |
No Yes |
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k. I set goals with my health care provider about how to eat healthier. |
No Yes |
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l. I set goals with my health care provider about how to be more physically active regularly. |
No Yes |
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18. How certain are you that…? (please check one response for each statement)
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Not at all certain |
Not very certain |
Not sure how certain I am |
Somewhat certain |
Very certain |
a. You can reach healthy eating goals if you set them with your health care provider? |
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b. You can reach physical activity goals if you set them with your health care provider? |
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c. People who are important to you will help you reach your healthy eating goals? |
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d. People who are important to you will help you reach your physical activity goals? |
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e. You have the information you need to reach your healthy eating goals? |
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f. You have the information you need to reach your physical activity goals? |
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g. You know what practical steps to take to reach your healthy eating goals? |
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h. You know what practical steps to take to reach your physical activity goals? |
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19. How much do you agree with each of the following statements
about your health care visit today?
(please check one
response for each statement)
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Strongly Disagree |
Disagree |
Not sure if I agree or disagree |
Agree |
Strongly Agree |
a. Healthy eating is something that I should discuss with my health care provider. |
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b. Physical activity is something I should discuss with my health care provider. |
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c. I did not learn anything new about healthy eating at my visit today. |
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d. I did not learn anything new about physical activity at my visit today. |
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e. It is important to me to reach the healthy eating goals I just set. |
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f. It is important to me to reach the physical activity goals I just set. |
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g. Talking to my health care provider helped me think about changing what I eat. |
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h. Talking to my health care provider helped me think about being more active. |
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i. Because of my visit today, I will try to eat more healthy foods. |
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j. Because of my visit today, I will try to change how much or the type of physical activity I get. |
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20. How much do you agree with these statements? (please check one answer for each statement)
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Strongly Disagree |
Disagree |
Not sure if I agree or disagree |
Agree |
Strongly Agree |
a. I will be able to reach my healthy eating goals even if I have to learn new information about buying or making healthier foods. |
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b. I will be able to reach my healthy eating goals even if it takes me more than one try to succeed. |
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c. I will be able to reach my healthy eating goals even if it takes me more time to make meals. |
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d. I will be able to reach my healthy eating goals even if it does not taste as good as what I usually eat. |
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e. I will be able to reach my healthy eating goals when I am worried. |
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f. I will be able to reach my healthy eating goals when my family does not want to eat what I do. |
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g. I will be able to reach my physical activity goals even if it takes me more than one try to succeed. |
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h. I will be able to reach my physical activity goals even if no one else thinks it is important. |
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i. I will be able to reach my physical activity goals even if the weather is bad. |
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j. I will be able to reach my physical activity goals even if I don’t have an exercise partner. |
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k. I have the skills I need to be more physically active. |
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l. At future visits I will talk to my health care provider about healthy eating issues if they don’t talk to me about them first. |
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m. At future visits I will talk to my health care provider about physical activity issues if they don’t talk to me about them first. |
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21. Please indicate if you agree or disagree with each of the following statements (Column A) and how you felt about this before today’s health care visit (Column B). (please check one response in each of Column A and Colum B for each statement)
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Column A |
Column B |
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Disagree |
Not Sure |
Agree |
Disagreed |
Not Sure |
Agreed |
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a. Some people are born to be fat and some thin; there is not much you can do to change this. |
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b. People who are overweight or underweight are more likely to have health problems than people who are not. |
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c. As you get older you need less physical activity every day. |
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d. Even if you are not overweight or underweight, what you eat can make a difference in your health. |
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e. Even if you are not overweight or under- weight, how much physical activity you do every day can make a difference in your health. |
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f. There are good foods and bad foods. |
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22. Please indicate if you plan to make changes in your physical activity level and in what you eat. If you don't plan on making any changes choose an option that indicates why (please check one response for each behavior).
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I plan to make |
I am already doing |
Other things are more important to me |
I don’t know |
Other |
a. My Physical Activity |
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b. What I Eat |
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23. Do you have any other comments about the “My Bright Future: Physical Activity and Healthy Eating Guide and Tip Sheets?” (PLEASE PRINT)
Bright
Futures for Women’s Health and Wellness | Healthy eating and
Physical Activity Materials | Adolescent Questionnaire
| File Type | application/msword |
| File Title | Bright Futures for Women’s Health and Wellness |
| Author | Laura Sternesky |
| Last Modified By | HRSA |
| File Modified | 2007-05-10 |
| File Created | 2007-05-10 |