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Data Collection Instruments
Form Approval
OMB No. 0925-XXXX
Expires XX/XX/XX
PHYSICIAN SURVEY OF PRACTICES ON DIET,
PHYSICAL ACTIVITY, AND WEIGHT CONTROL:
ADULT QUESTIONNAIRE
Conducted by:
National Institute of Child Health
and Human Development (NICHD)
Public reporting burden for this response is estimated to be an average of xx minutes per questionnaire including time for reviewing instructions. Send
comments regarding this burden statement or any other aspect of this collection of information including suggestions for reducing this burden to
XXXXXXXXX. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0925-xxxx.
INTRODUCTION
The Physician Survey of Practices on Diet, Physical Activity, and Weight Control – Adult
Questionnaire is sponsored by the National Cancer Institute in collaboration with The Office
of Behavioral and Social Science Research, National Institute of Child Health and Human
Development, the National Institute of Diabetes and Digestive and Kidney Diseases, and the
Centers for Disease Control and Prevention. It is being sent to a random sample of Family
Medicine Physicians, General Internists, Obstetrician/Gynecologists, and Pediatricians.
Your name and contact information were provided to us by the American Medical
Association.
This survey asks about the evaluation and guidance you provide to your patients about diet,
weight, and physical activity.
The information you provide will remain confidential to the fullest extent of the law. Your
answers will be aggregated with those of other respondents in reports to NCI and any other
parties.
Participation is voluntary, and there are no penalties to you for not responding. However,
not responding could seriously affect the accuracy of final results, and your point of view
may not be adequately represented in the survey findings.
INSTRUCTIONS
When you answer, include ALL the patients you treat in the age range specified.
Answer the questions regarding your main primary care practice location (i.e., the
practice setting where you spend the most hours per week, at which the majority of
your patients are seen.)
Use an X or check mark in the box to indicate your answers.
Use the line provided in “Other (specify): ___________________” if your answer is not
adequately represented by available choices
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
SECTION A: PATIENT POPULATIONS TREATED
A1.
Please indicate the patient population(s) you treat.
CHECK ONE IN EACH ROW
YES
a.
Do you see infants, < 2 years?
b.
Do you see children 2-11 years?
c.
Do you see adolescents 12-17 years?
d.
Do you see adults 18-65 years?
e.
Do you see older adults 65+ years?
NO
THOUGH YOU MAY TREAT A WIDE RANGE OF PATIENTS, THE
FOLLOWING QUESTIONS FOCUS ON ADULT POPULATIONS YOU
TREAT, AGE 18 YEARS AND OLDER.
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
The next questions are about practices involving adult patients 18 years and older.
A2.
During routine well-patient physical exams of your adult (18 years and older) patients:
CHECK ONE IN EACH ROW
NEVER
a.
How often do you assess diet, or physical
activity?
b.
As a general policy, for your entire adult
patient population, how often do you
promote:
RARELY
SOMETIMES
OFTEN
ALWAYS
Healthy Diet / Nutrition
Physical Activity
A3.
For your adult patients WITHOUT weight-related chronic disease who have an unhealthy
diet, are insufficiently active, or are overweight:
How often do you…:
CHECK ONE IN EACH ROW
NEVER
a.
Provide general counseling for changing
diet, physical activity, or weight?
b.
Provide specific guidance on:
Diet/Nutrition (e.g. “Eat more fruits and
vegetables” or “Increase your calcium”)?
Physical Activity (e.g. “Increase your
exercise by walking daily”)?
Weight Control (e.g. “Lose X lbs by
cutting calories and exercising”)?
c.
Refer these patients to another health
professional or program outside of your
practice for further evaluation and/or
management?
d.
Systematically track/follow patients over
time concerning behaviors or other
measures of progress related to diet,
physical activity, or weight?
RARELY
SOMETIMES
OFTEN
ALWAYS
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
A4.
For your adult patients WITH weight-related chronic disease who have an unhealthy diet,
are insufficiently active, or are overweight:
How often do you…:
CHECK ONE IN EACH ROW
NEVER
a.
Provide general counseling for changing
diet, physical activity, or weight?
b.
Provide specific guidance on:
RARELY
SOMETIMES
OFTEN
ALWAYS
Diet/Nutrition (e.g. “Eat more fruits and
vegetables” or “Increase your calcium”)?
Physical Activity (e.g. “Increase your
exercise by walking daily”)?
Weight Control (e.g. “Lose X lbs by
cutting calories and exercising”)?
c.
Refer these patients to another health
professional or program outside of your
practice for further evaluation and/or
management?
d.
Systematically track/follow patients over
time concerning behaviors or other
measures of progress related to diet,
physical activity, or weight?
A5.
If you assess diet, HOW do you assess it?
Not applicable. I do not assess diet. GO TO A6.
a.
General questions about food groups (e.g., fruits and vegetables)
b.
General questions about dietary patterns (e.g., fast food)
c.
Specific questions about diet components (e.g., calcium, protein)
d.
Standardized diet questionnaire
e.
Other (Please specify)
CHECK ONE IN EACH ROW
YES
NO
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
A6.
If you assess physical activity, HOW do you assess it?
Not applicable. I do not assess physical activity. GO TO A7.
CHECK ONE IN EACH ROW
YES
a.
General questions about amount of physical activity
b.
General questions about amount of sedentary activity (e.g. TV
watching)
c.
Specific questions about duration, intensity, and type of physical
activity
d.
Standardized physical activity questionnaire
e.
Other (Please specify)
A7.
How often do you assess the following?
Every
well
patient
visit
a. Weight measured on
a scale
b. Weight reported by
the patient
c. Body mass Index
(BMI)
d. Waist circumference
e. Height
Every
visit
NO
CHECK ALL THAT APPLY
Annually
As
clinically
indicated
Never
Other interval
(specify)
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
A8.
How often are the following tests utilized in your practice for overweight/obese adult
patients?
CHECK ALL THAT APPLY
Not
Applicable
(Do not
utilize)
a.
Every
2
years
More
than
twice
a year
Every
Annually
6
months
Other
(Specify):
Random blood glucose
Patients with additional
risk factors
Patients without
additional risk factors
b.
Fasting blood glucose
Patients with additional
risk factors
Patients without
additional risk factors
A9.
Have you ever, or are you currently…
CHECK TWO FOR EACH ROW
EVER
Yes
a.
Prescribing pharmacological treatments for weight control to
any of your patients?
b.
Referring any of your patients for surgical treatment for obesity?
No
CURRENTLY
Yes
No
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
A10.
When you treat each of the following conditions, do you address diet/nutrition, physical
activity or weight control?
CHECK ALL THAT APPLY
Do Not Treat
this Condition
a.
Abnormal body weight/BMI
b.
Abnormal lipid profile
c.
Hypertension
d.
Eating disorders such as anorexia or
bulimia
e.
Asthma
f.
Diabetes mellitus (Type II)
g.
Coronary heart disease
h.
Cancer
i.
Arthritis
j.
Sleep apnea
k.
Chronic obstructive lung disease
l.
Back pain/problems/injury
m.
Family history of diabetes mellitus
n.
Family history of heart disease
o.
Family history of cancer
p.
Other, specify:
Diet
Physical
Activity
Weight
Control
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
SECTION B: BARRIERS TO PATIENT ASSESSMENT,
EVALUATION, and MANAGEMENT
B1.
Which of the following are the TOP 3 BARRIERS to evaluating and/or managing your
patients’ diet/nutrition, physical activity, and weight in your practice?
CHECK THE TOP 3 BARRIERS
a.
Not enough time
b.
Not part of my role
c.
I am not adequately trained in this area
d.
Too difficult to evaluate and manage
e.
Inadequate reimbursement
f.
Lack of adequate referral services for diet, physical activity and weight
g.
Patients are not interested in improving their diet, physical activity, or
weight levels
h.
Fear of offending the patient
i.
Too difficult for patients to change their behavior
j.
Lack of effective tools and information to give to patients.
k.
Lack of effective treatment options
l.
Other (specify):
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
B2.
Relative to your current practice, what are the TOP 3 improvements that could assist
you in reducing patients’ health issues related to diet, physical activity, and weight?
CHECK THE TOP 3 IMPROVEMENTS
a.
Ways to more easily identify problems with diet, physical activity, and weight
b.
Easy-to-understand patient management guidelines
c.
Better reimbursement for counseling
d.
Better tools to communicate diet, physical activity, or weight problems to
patient or family
e.
Better counseling tools to guide patients toward lifestyle modification
f.
More training for your staff in evaluating and managing patient diet, physical
activity, and weight
g.
More training for you in evaluating and managing patient diet, physical
activity, and weight
h.
Better information systems to document and track goals in the medical
record
i.
Better information systems to identify appropriate referral services
j.
Better mechanism to connect patient to specific referral services
k.
Other (specify):
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
PERSONAL BELIEFS
B3.
Please indicate how strongly you agree with each of the following statements.
CHECK ONE IN EACH ROW
Strongly
Disagree
a.
b.
c.
d.
e.
f.
g.
Physicians have a responsibility to
promote the following with their
patients:
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
Patients are more likely to adopt
healthier lifestyles if physicians
counsel them to do so.
There are effective strategies
and/or tools to help patients:
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
I am confident in my ability to
counsel my patients:
eat a healthy diet.
to be adequately physically active.
maintain a healthy weight or lose
weight.
I am effective at helping my patients
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
In order to effectively encourage
patient adherence to a healthy
lifestyle, a physician must adhere
to one him/herself.
Specifically, a physician will be
able to provide more credible and
effective counseling if he/she:
eats a healthy diet.
is adequately physically active.
maintains a healthy weight or
loses weight.
Disagree
Somewhat
Neither
Agree nor
Disagree
Agree
Somewhat
Strongly
Agree
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
B4.
According to current guidelines, at what BMI level are adult patients (18 years or
older) considered to be…
CHECK ONE IN EACH ROW
≥ 20 kg/m
a.
Overweight?
b.
Obese?
B5.
2
≥ 25 kg/m2
≥ 30 kg/m2
≥ 35 kg/m2
Don’t Know
According to current guidelines, in what BMI percentile range are children or
adolescents (2-17 years) considered to have healthy weight? CHECK ONE
5th - 65th percentile
5th - 75th percentile
5th - 85th percentile
5th - 95th percentile
Other, specify
DON’T KNOW
B6.
According to current guidelines, for adults, 18 and older, how much moderate
physical activity is recommended (on most days of the week) for general health and
prevention of chronic diseases? CHECK ONE
20 minutes
30 minutes
40 minutes
60 minutes
90 minutes
Other, specify
DON’T KNOW
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
B7.
According to current guidelines, for adults, 18 and older, how many servings of
fruits and vegetables should a person have in a day? CHECK ONE
3 servings
5 servings
7 servings
It depends on daily calorie intake
Other, specify
DON’T KNOW
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
SECTION C: YOUR PERSONAL HEALTH STATUS / HEALTH BEHAVIORS
C1.
C2.
In general, would you say your health is:
Excellent
CHECK ONE
Very Good
Good
Fair
Poor
These questions are about the foods you ate or drank during the PAST MONTH, that is, the
past 30 days. Please include meals and snacks eaten at home, at work or school, in
restaurants, and any place else.
CHECK ONE IN EACH ROW
Never
a.
b.
c.
d.
e.
How often did you
drink 100%
FRUIT Juice,
such as orange,
mango, apple, or
grape juices? Do
NOT include fruit
drinks
How often did you
eat FRUIT?
INCLUDE fresh,
frozen or canned
fruit. Do NOT
include juices.
How often did you
eat FRENCH
FRIES, or home
fries, or hash
brown potatoes?
How often did you
eat other
POTATOES?
INCLUDE baked,
boiled, mashed or
potato salad.
Not including
potatoes (and not
counting rice),
how often did you
eat OTHER
VEGETABLES?
1-3
times
last
mont
h
1-2
times
per
week
3-4
times
per
week
5-6
times
per
week
1
tim
e
per
day
2
times
per
day
3 or
more
times
per
day
4 or
more
times
per
day
5 or
more
times
per
day
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
Physical Activity
C3. Moderate physical activities make you breathe somewhat harder than normal. During the
last 7 days, did you do any moderate physical activities for at least 10 minutes? Think
about activities such as bicycling, swimming, brisk walking, dancing or gardening.
NO GO TO C4
YES
a.
On how many of the past 7 days did you do moderate physical activities? *
|___| DAYS
b.
In the past 7 days, on a typical day in which you did moderate physical
activities, how much time did you spend doing them? *
|___|___|___| MINUTES PER DAY
C4. Vigorous activities make you breathe much harder than normal. Now think about
vigorous activities you did that take hard physical effort, such as aerobics, running,
soccer, fast bicycling, or fast swimming. During the last 7 days, did you do any
vigorous physical activities in your free time for at least 10 minutes?
NO GO TO C5
YES
a. On how many of the past 7 days did you do vigorous physical activities?
|___| DAYS
b. In the past 7 days, on a typical day in which you did vigorous physical activities, how
much time did you spend doing them?
|___|___|___| MINUTES PER DAY
C5. Now think about activities specifically designed to STRENGTHEN your muscles, such as
lifting weights or other strength-building exercises. Include all such activities even if you
have included them before. During the last 7 days, did you do activities to strengthen
your muscles?
NO GO TO C6
YES
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
Height and Weight Status
C6.
How tall are you without shoes?
|___| FEET
|___|___| INCHES
IF YOU ARE FEMALE AND CURRENTLY PREGNANT, GO TO C7a.
OTHERWISE GO TO C7.
C7.
How much do you weigh without shoes?
|___|___|___| POUNDS
C7a.
If you are currently pregnant, how much did you weigh before your
pregnancy?
|___|___|___| POUNDS
C8.
Are you currently trying to: CHECK ONE
Lose weight
Gain weight
Maintain weight
Not trying to make a change
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
PHYSICIAN CHARACTERISTICS
C9.
When were you born?
| 1 | 9 |
C10.
|
| YEAR
Are you… CHECK ONE
Female
Male
C11.
Do you consider yourself to be Hispanic or Latino/a? CHECK ONE
YES
NO
C12.
What do you consider to be your race? CHECK ONE OR MORE
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
C13.
a.
b.
During a typical month, approximately what percent of your professional time do
you spend in the following activities?
Percent of professional time
Providing Primary Care
Providing Subspecialty Care
Please specify:
____ ____ %
____ ____ %
c.
Research
____ ____ %
d.
Teaching
____ ____ %
e.
Administration
____ ____ %
f.
Other (specify):
____ ____ %
TOTAL
100%
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
PRACTICE CHARACTERISTICS
C14.
Which of the following categories best describes your main primary care practice
location? Are you a…
CHECK ALL THAT APPLY
a.
Full- or part-owner of a physician practice
b.
Employee of a physician-owned practice
c.
Employee of a large medical group or health care system
d.
Employee of a staff or group model HMO
e.
Employee of a university hospital or clinic
f.
Employee of a hospital or clinic not associated with a university
(including community health clinics)
g.
Other (specify):
C15.
Please estimate the number of patient visits that you have in a TYPICAL WEEK,
EXCLUDING patient visits while on-call (on-call is defined as time outside of
regularly scheduled clinical activity):
|___|___|___| Number of Patient Visits
DON’T KNOW
C16.
Approximately what percentage of the patients you treat is female?
|___|___|___| %
DON’T KNOW
C17.
Approximately what percentage of the patients you treat is Hispanic or
Latino?….(PLEASE GIVE YOUR BEST ESTIMATE)
CHECK ONE
a.
0-5%
b.
6-25%
c.
26-50%
d.
51-75%
e.
f.
76-100%
DON’T KNOW
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
C18.
Approximately what percentage of the patients you treat is….(PLEASE GIVE YOUR BEST
ESTIMATE)
PERCENTAGE OF PATIENTS
a.
White
___ ___ ___ %
b.
Black or African-American
___ ___ ___ %
c.
Asian
___ ___ ___ %
d.
Native Hawaiian or Other Pacific Islander
___ ___ ___ %
e.
American Indian or Alaska Native
___ ___ ___ %
TOTAL
C19.
1 0 0 %
Within a practice, there may be multiple clinical sites at which medical care is delivered.
CHECK ONE
Does this practice have more than one clinical site?
C20.
YES
NO
About how many physicians, nurse practitioners, and physician assistants provide care
in all of the clinical sites within this practice? CHECK ONE
1
2–5
6 – 20
More than 20 and fewer than 100
More than 100
DON’T KNOW
C21.
If this survey were available on the Internet as a web-based questionnaire, would you
prefer to fill it out online, or is a paper and pencil survey more convenient for you?
CHECK ONE
I prefer paper and pencil
I prefer a web-based questionnaire
I have no preference
Other (please specify): ________________________________________________
Physician Survey of Practices on Diet, Physical Activity, and Weight Control:
Adult Questionnaire
C22.
We would like to obtain additional information about aspects of the practice that
support disease prevention activities. However, we know your time is limited, so
we’d like to send your office administrator a short questionnaire of about 20
questions related to the structure of your practice and the roles of different staff that
work there. Please give us the name of your office administrator, or indicate whether
it would be better for us to send the brief questionnaire to you.
Check one:
Dr.
Mr.
Ms.
Mrs.
First Name: |___|___|___|___|___|___|___|
Last Name: |___|___|___|___|___|___|___|___|___|___|
The office administrator in my practice is less familiar with the clinical roles of
my staff; I am the best person to answer questions about my practice.
If you have any comments about the questionnaire, individual questions, or the burden,
please make them here. We appreciate your participation and feedback.
Form Approval
OMB No. 0925-XXXX
Expires XX/XX/XX
PHYSICIAN SURVEY OF PRACTICES ON DIET,
PHYSICAL ACTIVITY, AND WEIGHT CONTROL
CHILD/ADOLESCENT QUESTIONNAIRE
Conducted by:
National Institute of Child Health
and Human Development (NICHD)
Public reporting burden for this response is estimated to be an average of xx minutes per questionnaire including time for reviewing instructions. Send
comments regarding this burden statement or any other aspect of this collection of information including suggestions for reducing this burden to
XXXXXXXXX. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0925-xxxx.
INTRODUCTION
The Physician Survey of Practices on Diet, Physical Activity, and Weight Control –
Child/Adolescent Questionnaire is sponsored by the National Cancer Institute in
collaboration with The Office of Behavioral and Social Science Research, National Institute of
Child Health and Human Development, the National Institute of Diabetes and Digestive and
Kidney Diseases and the Centers for Disease Control and Prevention. It is being sent to a
random sample of Family Medicine Physicians, General Internists,
Obstetrician/Gynecologists, and Pediatricians. Your name and contact information were
provided to us by the American Medical Association.
This survey asks about the evaluation and guidance you provide to your patients about diet,
weight, and physical activity.
The information you provide will remain confidential to the fullest extent of the law. Your
answers will be aggregated with those of other respondents in reports to NCI and any other
parties.
Participation is voluntary, and there are no penalties to you for not responding. However,
not responding could seriously affect the accuracy of final results, and your point of view
may not be adequately represented in the survey findings.
INSTRUCTIONS
When you answer, include ALL the patients you treat in the age range specified.
Answer the questions regarding your main primary care practice location (i.e., the
practice setting where you spend the most hours per week, at which the majority of
your patients are seen.)
Use an X or check mark in the box to indicate your answers.
Use the line provided in “Other (specify): ___________________” if your answer is not
adequately represented by available choices
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
SECTION A: PATIENT POPULATIONS TREATED
A1.
Please indicate the patient population(s) you treat.
CHECK ONE IN EACH ROW
YES
a.
Do you see infants, < 2 years?
b.
Do you see children 2-11 years?
c.
Do you see adolescents 12-17 years?
d.
Do you see adults 18-65 years?
e.
Do you see older adults 65+ years?
NO
Though you may treat a wide range of patients, this
survey focuses on your practices involving your
child/adolescent patients (age 2-17).
1
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
The next questions are about practices involving child/adolescent patients (age 2-17).
A2.
During routine well-patient physical exams of your child/adolescent patients (age 2-17):
CHECK ONE IN EACH ROW
NEVER
a.
How often do you assess diet, or
physical activity?
b.
As a general policy for your entire
child/adolescent patient population, how
often do you promote:
RARELY
SOMETIMES
OFTEN
ALWAYS
Healthy Diet / Nutrition?
Physical Activity?
A3.
For your child/adolescent patients who have unhealthy diet, are insufficiently active,
are overweight, or are at risk for weight-related chronic disease:
CHECK ONE IN EACH ROW
NEVER
a.
How often do you provide general
counseling for changing diet, physical
activity, or weight?
b.
How often do you provide specific
guidance on:
Diet/Nutrition (e.g. “Eat more fruits and
vegetables” or “Increase your
calcium”)?
Physical Activity (e.g. “Increase your
exercise by walking daily”)?
c.
d.
Weight Control (e.g. “Lose X lbs by
cutting calories and exercising”)?
How often do you refer these patients to
another health professional or program
outside of your practice for further
evaluation and/or management?
How often do you systematically
track/follow patients over time
concerning behaviors or other measures
of progress related to diet, physical
activity, or weight?
2
RARELY
SOMETIMES
OFTEN
ALWAYS
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
A4.
When you assess diet in patients 2-17 years, HOW do you assess it?
Not applicable. I do not assess diet. GO TO A5
CHECK ONE IN EACH ROW
YES
a.
General questions about food groups (e.g., fruits and vegetables)
b.
General questions about dietary patterns (e.g., fast food)
c.
Specific questions about diet components (e.g., calcium, protein)
d.
Standardized diet questionnaire
e.
Other (Please specify)
NO
When you assess physical activity in patients 2-17 years, HOW do you assess it?
A5.
Not applicable. I do not assess physical activity. GO TO A6
CHECK ONE IN EACH ROW
YES
a.
General questions about amount of physical activity
b.
d.
General questions about amount of sedentary activity (e.g. TV
watching)
Specific questions about duration, intensity, and type of physical
activity
Standardized physical activity questionnaire
e.
Other (Please specify)
c.
3
NO
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
A6.
How often do you assess or review the following in children or adolescents (ages 2-17)?
CHECK ALL THAT APPLY
Every
well
patient
visit
Every
visit
Annually
As
clinically
indicated
Never
Other interval
(Specify)
a. Weight measured in
office
Height measured in
b.
office
c. Body Mass Index
Waist circumference or
d.
waist-to-hip ratio
Weight-for-age growth
e.
charts
Stature-for-age growth
f.
charts
g. BMI-for-age growth chart
A7.
How often do you assess or review the following in infants (ages <2)?
CHECK ALL THAT APPLY
Every
well
patient
visit
Every
visit
Annually
a. Weight measured in
office
Length measured in
b.
office
c. Growth chart
Weight-for-length growth
d.
charts
Weight-for-age growth
e.
charts
Length-for-age growth
f.
chart
4
As
clinically
indicated
Never
Other interval
(Specify)
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
A8.
For your overweight/obese child/adolescent patients (ages 2-17), at what age do you begin
performing the following tests?
If you DO NOT perform these tests, please check “N/A”.
CHECK ONE IN EACH ROW
N/A
a
Age in Years
Random blood glucose testing
Patients with risk factors or family history
Patients without risk factors or family history
b Fasting blood glucose testing
Patients with risk factors or family history
Patients without risk factors or family history
A9.
How often are the following tests utilized in your practice for overweight/obese
children/adolescent patients (ages 2-17)?
If you DO NOT perform these tests, please check “N/A”.
CHECK ALL THAT APPLY
Every
Every
2
N/A
a.
years
Random blood glucose
Patients with additional risk
factors
Patients without additional
risk factors
b.
Fasting blood glucose
Patients with additional risk
factors
Patients without additional
risk factors
5
Annually
6
months
More
than
twice
a year
Other
(Specify):
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
A10.
When you treat each of the following conditions for your child/adolescent patients (ages
2-17), do you address diet/nutrition, physical activity or weight control?
CHECK ALL THAT APPLY
Do Not Treat
this Condition
a.
Abnormal body weight/BMI
b.
Elevated blood pressure
c.
Abnormal lipid profile
d.
Eating disorders such as anorexia or
bulimia
e.
Asthma
f.
Diabetes mellitus (Type II)
g.
Family history of diabetes mellitus
h.
Family history of heart disease
i.
Family history of cancer
j.
Other, specify:
6
Diet
Physical
Activity
Weight
Control
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
SECTION B: BARRIERS TO PATIENT ASSESSMENT,
EVALUATION, and MANAGEMENT
B1.
Which of the following are the TOP 3 BARRIERS to evaluating and/or managing your
patients’ diet/nutrition, physical activity, and weight in your practice?
CHECK THE TOP 3 BARRIERS
a.
Not enough time
b.
Not part of my role
c.
I am not adequately trained in this area
d.
Too difficult to evaluate and manage
e.
Inadequate reimbursement
f.
Lack of adequate referral services for diet, physical activity and weight
g.
Patients are not interested in improving their diet, physical activity, or
weight levels
h.
Fear of offending the patient
i.
Too difficult for patients to change their behavior
j.
Lack of effective tools and information to give to patients.
k.
Lack of effective treatment options
l.
Other (specify):
7
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
B2.
Relative to your current practice, what are the TOP 3 improvements that could assist
you in reducing patients’ health issues related to diet, physical activity, and weight?
CHECK THE TOP 3 IMPROVEMENTS
a.
Ways to more easily identify problems with diet, physical activity, and weight
b.
Easy-to-understand patient management guidelines
c.
Better reimbursement for counseling
d.
Better tools to communicate diet, physical activity, or weight problems to
patient or family
e.
Better counseling tools to guide patients toward lifestyle modification
f.
More training for your staff in evaluating and managing patient diet, physical
activity, and weight
g.
More training for you in evaluating and managing patient diet, physical
activity, and weight
h.
Better information systems to document and track goals in the medical
record
i.
Better information systems to identify appropriate referral services
j.
Better mechanism to connect patient to specific referral services
k.
Other (specify):
8
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
B3.
PERSONAL BELIEFS
Please indicate how strongly you agree with each of the following statements.
CHECK ONE IN EACH ROW
Strongly
Disagree
a.
b.
c.
d.
e.
f.
g.
Physicians have a responsibility
to promote the following with
their patients:
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
Patients are more likely to adopt
healthier lifestyles if physicians
counsel them to do so.
There are effective strategies
and/or tools to help patients:
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
I am confident in my ability to
counsel my patients:
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
I am effective at helping my
patients
eat a healthy diet.
be adequately physically active.
maintain a healthy weight or lose
weight.
In order to effectively encourage
patient adherence to a healthy
lifestyle, a physician must
adhere to one him/herself.
Specifically, a physician will be
able to provide more credible
and effective counseling if
he/she:
eats a healthy diet.
is adequately physically active.
maintains a healthy weight or
loses weight.
9
Disagree
Somewhat
Neither
Agree nor
Disagree
Agree
Somewhat
Strongly
Agree
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
B4.
According to current guidelines, at what BMI level are adult patients (18 years or
older) considered to be…
CHECK ONE IN EACH ROW
≥ 20 kg/m
a.
Overweight?
b.
Obese?
B5.
2
≥ 25 kg/m2
≥ 30 kg/m2
≥ 35 kg/m2
Don’t Know
According to current guidelines, in what BMI percentile range are children or
adolescents (2-17 years) considered to have healthy weight? CHECK ONE
5th - 65th percentile
5th - 75th percentile
5th - 85th percentile
5th - 95th percentile
Other, specify
DON’T KNOW
B6.
According to current guidelines, for adults, 18 and older, how much moderate
physical activity is recommended (on most days of the week) for general health and
prevention of chronic diseases? CHECK ONE
20 minutes
30 minutes
40 minutes
60 minutes
90 minutes
Other, specify
DON’T KNOW
10
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
B7.
According to current guidelines, for adults, 18 and older, how many servings of
fruits and vegetables should a person have in a day? CHECK ONE
3 servings
5 servings
7 servings
It depends on daily calorie intake
Other, specify
DON’T KNOW
11
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
SECTION C: YOUR PERSONAL HEALTH STATUS / HEALTH BEHAVIORS
C1.
C2.
In general, would you say your health is:
Excellent
CHECK ONE
Very Good
Good
Fair
Poor
These questions are about the foods you ate or drank during the PAST MONTH, that is, the
past 30 days. Please include meals and snacks eaten at home, at work or school, in
restaurants, and any place else.
CHECK ONE IN EACH ROW
Never
a.
b.
c.
d.
e.
1-3
times
last
month
1-2
times
per
week
3-4
times
per
week
How often did you
drink 100% FRUIT
Juice, such as
orange, mango,
apple, or grape
juices? Do NOT
include fruit drinks
How often did you
eat FRUIT?
INCLUDE fresh,
frozen or canned
fruit. Do NOT
include juices.
How often did you
eat FRENCH
FRIES, or home
fries, or hash
brown potatoes?
How often did you
eat other
POTATOES?
INCLUDE baked,
boiled, mashed or
potato salad.
Not including
potatoes (and not
counting rice), how
often did you eat
OTHER
VEGETABLES?
12
5-6
times
per
week
1
time
per
day
2
times
per
day
3 or
more
times
per
day
4 or
more
times
per
day
5 or
more
times
per
day
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
Physical Activity
C3. Moderate physical activities make you breathe somewhat harder than normal. During the
last 7 days, did you do any moderate physical activities for at least 10 minutes? Think about
activities such as bicycling, swimming, brisk walking, dancing or gardening.
NO GO TO C4
YES
a.
On how many of the past 7 days did you do moderate physical activities?
|___| DAYS
b.
In the past 7 days, on a typical day in which you did moderate physical
*
activities, how much time did you spend doing them?
|___|___|___| MINUTES PER DAY
C4. Vigorous activities make you breathe much harder than normal. Now think about
vigorous activities you did that take hard physical effort, such as aerobics, running,
soccer, fast bicycling, or fast swimming. During the last 7 days, did you do any vigorous
physical activities in your free time for at least 10 minutes?
NO GO TO C5
YES
a. On how many of the past 7 days did you do vigorous physical activities?
|___| DAYS
b. In the past 7 days, on a typical day in which you did vigorous physical activities, how
much time did you spend doing them?
|___||___||___| MINUTES PER DAY
C5. Now think about activities specifically designed to STRENGTHEN your muscles, such as
lifting weights or other strength-building exercises. Include all such activities even if you
have included them before. During the last 7 days, did you do activities to strengthen your
muscles?
NO GO TO C6
YES
13
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
Height and Weight Status
C6.
How tall are you without shoes?
|___| FEET
|___|___| INCHES
IF YOU ARE FEMALE AND CURRENTLY PREGNANT, GO TO C7a.
OTHERWISE GO TO C7.
C7.
How much do you weigh without shoes?
|___|___|___| POUNDS
C7a.
If you are currently pregnant, how much did you weigh before your
pregnancy?
|___|___|___| POUNDS
C8.
Are you currently trying to: CHECK ONE
Lose weight
Gain weight
Maintain weight
I am not trying to do anything about my weight
14
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
PHYSICIAN CHARACTERISTICS
C9.
When were you born?
| 1 | 9 |
C10.
|
| YEAR
Are you… CHECK ONE
Female
Male
C11.
Do you consider yourself to be Hispanic or Latino/a? CHECK ONE
YES
NO
C12.
What do you consider to be your race? CHECK ONE OR MORE
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
C13.
a.
b.
During a typical month, approximately what percent of your professional time do
you spend in the following activities?
Percent of professional time
Providing Primary Care
____ ____ %
Providing Subspecialty Care
____ ____ %
Please specify:
c.
Research
____ ____ %
d.
Teaching
____ ____ %
e.
Administration
____ ____ %
f.
Other (specify):
____ ____ %
TOTAL
100%
15
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
PRACTICE CHARACTERISTICS
C14.
Which of the following categories best describes your main primary care practice
location? Are you a…
CHECK ALL THAT APPLY
a.
Full- or part-owner of a physician practice
b.
Employee of a physician-owned practice
c.
Employee of a large medical group or health care system
d.
Employee of a staff or group model HMO
e.
Employee of a university hospital or clinic
f.
Employee of a hospital or clinic not associated with a university
(including community health clinics)
g.
Other (specify):
C15.
Please estimate the number of patient visits that you have in a TYPICAL WEEK,
EXCLUDING patient visits while on-call (on-call is defined as time outside of
regularly scheduled clinical activity):
|___|___|___| Number of Patient Visits
DON’T KNOW
C16.
Approximately what percentage of the patients you treat is female?
|___|___|___| %
DON’T KNOW
C17.
Approximately what percentage of the patients you treat is Hispanic or
Latino?….(PLEASE GIVE YOUR BEST ESTIMATE)
CHECK ONE
a.
0-5%
b.
6-25%
c.
26-50%
d.
51-75%
e.
f.
76-100%
DON’T KNOW
16
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
C18.
Approximately what percentage of the patients you treat is...(PLEASE GIVE YOUR BEST
ESTIMATE)
PERCENTAGE OF PATIENTS
a.
White
___ ___ ___ %
b.
Black or African-American
___ ___ ___ %
c.
Asian
___ ___ ___ %
d.
Native Hawaiian or Other Pacific Islander
___ ___ ___ %
e.
American Indian or Alaska Native
___ ___ ___ %
TOTAL
C19.
1 0 0 %
Within a practice, there may be multiple clinical sites at which medical care is delivered.
CHECK ONE
Does this practice have more than one clinical site?
C20.
YES
NO
About how many physicians, nurse practitioners, and physician assistants provide care
in all of the clinical sites within this practice? CHECK ONE
1
2–5
6 – 20
More than 20 and fewer than 100
More than 100
DON’T KNOW
C21.
If this survey were available on the Internet as a web-based questionnaire, would you
prefer to fill it out online, or is a paper and pencil survey more convenient for you?
CHECK ONE
I prefer paper and pencil
I prefer a web-based questionnaire
I have no preference
Other (please specify): ________________________________________________
17
Physician Survey of Practices on Diet, Physical Activity, and Weight Control
Child/Adolescent Questionnaire
C22.
We would like to obtain additional information about aspects of the practice that
support disease prevention activities. However, we know your time is limited, so we’d
like to send your office administrator a short questionnaire of about 20 questions
related to the structure of your practice and the roles of different staff that work there.
Please give us the name of your office administrator, or indicate whether it would be
better for us to send the brief questionnaire to you.
Check one:
Dr.
Mr.
Ms.
Mrs.
First Name: |___|___|___|___|___|___|___|
Last Name: |___|___|___|___|___|___|___|___|___|___|
The office administrator in my practice is less familiar with the clinical roles of
my staff; I am the best person to answer questions about my practice.
If you have any comments about the questionnaire, individual questions, or the burden, please
make them here. We appreciate your participation and feedback.
18
Form Approval
OMB No. 0925-XXXX
Expires XX/XX/XX
Physician Survey of Practices on Diet,
Physical Activity and Weight Control
ADMINISTRATOR QUESTIONNAIRE
Conducted by:
National Institute of Child Health
and Human Development (NICHD)
Public reporting burden for this response is estimated to be an average of xx minutes per questionnaire including time for reviewing instructions. Send
comments regarding this burden statement or any other aspect of this collection of information including suggestions for reducing this burden to
XXXXXXXXX. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a
currently valid OMB control number. The OMB control number for this project is 0925-xxxx.
INTRODUCTION AND INSTRUCTIONS
The Physician Survey of Practices on Diet, Physical Activity, and Weight Control is
sponsored by the National Cancer Institute in collaboration with The Office of
Behavioral and Social Science Research, National Institute of Child Health and Human
Development, the National Institute of Diabetes and Digestive and Kidney Diseases and
the Centers for Disease Control and Prevention. Obesity, poor diet, and lack of physical
activity are recognized as major public health problems in the United States. The
Administrator Questionnaire asks about factors that could facilitate or hinder
physician's practices intended to address these problems.
The survey is being sent to a random sample of Family Medicine Physicians, General
Internists, Obstetrician/Gynecologists, and Pediatricians, and their associated
administrators. The following doctor in your office has participated in the physician
portion of the survey:
Please provide answers to the survey questions based on the patient characteristics,
clinical guidelines, and financial arrangements related to the clinical site listed above,
which should be the location at which the doctor practices medicine. You may need to
obtain information from multiple members of the clinic team.
The information you provide in this survey will remain confidential to the fullest extent
of the law. Your answers will be combined with those of other respondents in reports to
NCI and anyone else.
Participation is voluntary, and there are no penalties to you for not responding.
However, not responding could seriously affect the accuracy of final results, and your
point of view may not be adequately represented in the survey findings.
Use an X in the boxes to indicate your answers.
Use the line provided in “Other (Specify): _____________________” if your answer
is not adequately represented by available choices.
If you are not sure of an answer give your best estimate.
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
Section A. Practice Characteristics
A1.
Is this doctor’s office part of a…
CHECK ONE BOX
Solo practice GO TO A5
Group practice
Medical School
Hospital
Clinic or Community Health Center
Other (Specify)
A2.
Is this doctor’s office a…
CHECK ONE BOX
Single specialty practice
Multi-specialty practice, where physicians from more than one specialty provide
services
Other (Specify)
A3.
Who owns this doctor’s office?
CHECK ONE BOX
One or more physicians or a physician owned corporation
A health system or integrated delivery system
A health plan or insurance company
Federal, state or local government
A medical school, hospital, or related organization
Other (Specify)
1
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
A4.
About how many part time and full time physicians, nurse practitioners, and physician
assistants work in this office?
CHECK ONE BOX
A5.
|___|___|___|
Number of part time and full time physicians, nurse practitioners
and physician assistants
|___|___|___|
Number of physician, nurse practitioner and physician’s assistant full time
equivalents (FTEs)
Which of the following types of healthcare professionals work in this office?
PLACE AN “X” FOR ALL THAT APPLY
a. Nurse Practitioners or Clinical Nurse Specialist
b. Physician Assistants
c. Nurses (e.g., RN, LPN, LVN)
d. Dieticians/Nutritionists
e. Health Educator
f. Occupational/Physical therapists
g. Social workers
h. Psychologists
i. Medical Assistants
k. Other (Specify)
A6.
Where is this office located?
CHECK ONE BOX
Large City (Population over 500,000)
Medium City (Population 100,000-500,000)
Small City (Population under 100,000)
Rural Community
Other (Specify)
2
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
A7.
At this office, approximately how many patient visits with physicians, nurse
practitioners, or physician assistants occur during a typical week?
PLEASE GIVE YOUR BEST ESTIMATE
|___|___|___|
A8.
Number of patient visits per week
In this office, approximately what percentage of the patients is…
PLEASE GIVE YOUR BEST ESTIMATE
0-5%
6-25%
26-50%
a. Uninsured
b. Privately Insured
c. Medicare Insured
d. Medicaid Insured
3
51-75%
76-100%
Don’t Know
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
Section B. Clinical Policies and Procedures
B1.
In this office, who usually performs the following for patients?
PLACE AN “X” FOR ALL THAT APPLY IN EACH ROW AND EACH COLUMN
Measuring
weight
and height
a.
Physician
b.
Nurse practitioner or physician
assistant
c.
Counseling about,
diet, physical
activity, and weight
control
Other staff (Specify):
c.
No one does this
e.
Don’t know
B2.
Assessing
diet and
physical
activity
In this office, is there a standard protocol that requires that each patient have the
following assessed?
PLACE AN “X” IN EACH COLUMN AND EACH ROW
Diet
Physical Activity
Weight
a.
At each visit
Yes
No
Yes
No
Yes
No
b.
At new patient visit
Yes
No
Yes
No
Yes
No
c.
Annually
Yes
No
Yes
No
Yes
No
d.
Other timeframe (Specify)
Yes
No
Yes
No
Yes
No
e.
A standard protocol is
implemented ONLY for high
risk patients
Yes
No
Yes
No
Yes
No
4
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
B3.
Does this office provide preventive medicine/well patient visits?
YES, this site provides preventive/well patient visits
B3a.
If yes, do these visits include counseling for diet, physical activity, and weight
management?
YES
NO
No, this office does NOT provide preventive/well patient visits
I don’t know
B4.
What type of medical record system does this office use?
CHECK ONE BOX
Paper charts
Partial electronic medical records (e.g., lab results available electronically, but patient
history on paper)
In transition from paper to full electronic medical records
Full electronic medical records
5
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
B5.
Which of the following mechanisms does this office have to follow up with patients
who have received counseling within the practice on diet, physical activity, or weight
management?
CHECK ALL THAT APPLY
Verbal reminder from the physician or other staff during an office visit
Reminder by US Mail, telephone, or e-mail
Personalized Web page or other mechanism (Specify)
None of these
Don’t Know
B6.
Which of the following mechanisms does this office have to follow up with patients
who are referred out from your practice for counseling on diet, physical activity, or
weight management?
CHECK ALL THAT APPLY
Verbal reminder from the physician or other staff during an office visit
Reminder by US Mail, telephone, or e-mail
Personalized Web page or other mechanism (Specify)
None of these
Don’t Know
6
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
Section C. Information Resources
C1.
Please indicate which of the following information resources on diet, physical activity
or weight control are available in the waiting or exam rooms.
CHECK ALL THAT APPLY
a.
Brochures, pamphlets
b.
Video
c.
Flyers for related programs or services (e.g., weight loss or exercise program)
d.
Books/ Journal articles
e.
Magazines
f.
No materials are available for diet, physical activity, or weight control
C2.
Does the office have a newsletter that goes out to patients?
C2a.
Yes
GO TO C2a
No
GO TO C3
In the past 12 months, did any of the newsletters provide information about:
CHECK ALL THAT APPLY
Diet/Nutrition
Physical Activity
Weight Control
C3.
Does the office have a website?
Yes GO TO C3a
No
C3a.
GO TO D1
If yes, in the past 12 months, did the website provide information about:
CHECK ALL THAT APPLY
Diet/Nutrition
Physical Activity
Weight Control
7
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
Section D Billing and Reimbursement
D1. Do you review or work with billing data on a regular basis?
Yes GO TO D2
No. GO TO SECTION E, PAGE 10.
D2.
About what percentage of the office’s revenue is derived from the following sources?
Don’t know
FILL IN PERCENTAGE FOR EACH ROW. TOTAL MUST EQUAL 100%
PERCENTAGE OF REVENUE
a.
Fee-for-Service
___ ___ ___ %
b.
Capitation
___ ___ ___ %
c.
Other (Specify)
___ ___ ___ %
TOTAL
D3.
1 0 0 %
In this office, what types of coverage do your insured patients have? (If no patients
have insurance, please indicate N/A)
Don’t know
PLACE AN “X” IN ONE BOX IN EACH ROW
0-5%
a.
6-25%
Managed Care
(HMO/POS)
b. Managed Care (PPO)
c. Other (specify):
8
26-50%
51-75%
76-100%
N/A
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
D4.
Does this office bill for visits that involve counseling for diet, physical activity, and
weight control? (Under some systems, services are provided under capitation and are
not billed).
Yes, billed as treatment for a chronic or acute condition
Yes, billed as part of preventive medicine/well patient visit
No, not billed
Don’t know
D5.
Do physicians working in this office receive any incentive payments to engage in the
following?
PLACE AN “X” IN ONE BOX IN EACH ROW
Yes
a.
Diabetes screening
b.
Cancer screening
c.
Heart disease screening
d.
Diet counseling
e.
Physical activity counseling
f.
Weight counseling
9
No
Don’t Know
Physician Survey of Practices on Diet, Physical Activity and Weight Control
Administrator Questionnaire
Section E Personal Characteristics
E1.
What is your position or title?
E2.
How long have you been with the practice?
|
E3.
|
| Month or Years (Circle One)
If this survey were available on the Internet as a web-based questionnaire, would you
prefer to fill it out online, or is a paper and pencil survey more convenient for you?
CHECK ONE
I prefer paper and pencil
I prefer a web-based questionnaire
I have no preference
Other (please specify): ________________________________________________
Please add any comments in the space provided. We appreciate your participation and
feedback.
10
| File Type | application/pdf |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |