BFWHW Consumer Survey

Bright Futures for Women’s Health and Wellness (BFWHW) Initiative
Consumer Survey
Please answer the following questions by checking the circle or circles next to your answer:
1.

How old were you on your last birthday?

7.

{ 13-17
{ 18-24
{ 25-44
{ 45-64
{ 65+
2.

3.

4.

5.

6.

What types of services were you seeking here
today (check all that apply)?
{ Prenatal/maternity care
{ Routine check-up
{ Treatment for illness
{ Emotional health counseling
{ Support group
{ Other_______________________

Are you Hispanic or Latina?
{ Yes
{ No

8.

Which of the following would you say is your
race (please select one or more)?
{ White
{ Black
{ American Indian or Alaska Native
{ Asian
{ Native Hawaiian or other Pacific Islander

What is your overall satisfaction with receiving
services from this clinic?
{ Very satisfied
{ Mostly satisfied
{ Somewhat satisfied
{ Mostly unsatisfied
{ Very unsatisfied

9.

How comfortable are you talking to doctors and
other health care providers about your
emotional health and well-being?
{ Very comfortable
{ Mostly comfortable
{ Somewhat comfortable
{ Somewhat uncomfortable
{ Very uncomfortable

What is the highest level of education you have
completed?
{ Eighth grade or less
{ Some High School
{ High School/GED (General Educational
Development)
{ Some College, technical or trade school
{ College Degree
{ Graduate Degree
What is your marital status?
{ Single, never married
{ Married
{ Living with Partner/ Cohabitating
{ Separated/Divorced
{ Widowed
About how many times in the last 12 months
have you had an appointment with this clinic
for health care or other services?
{0
{ 1-3
{ 4-6
{ More than 6

10. In the past year, about how many times have
you talked about your emotional health and
well-being with a doctor, counselor or other
health care provider?
{0
{ 1-3
{ 4-6
{ More than 6
11. How satisfied have you been with your personal
life over the last month?
{ Very satisfied
{ Sometimes satisfied
{ Not satisfied or dissatisfied
{ Sometimes dissatisfied
{ Very dissatisfied

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 currently 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 15 minutes 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.

12. During the past month, how much of the time has
your daily life been full of things that were
interesting to you?
{ All of the time
{ Most of the time
{ Some of the time
{ None of the time

17. Do you think the BFWHW Emotional Wellness
Guide contains advice that you can use to feel
better about your life?
{ Yes, it contains very useful advice
{ Yes, it contains some useful advice
{ No, the advice is not useful
{ Unsure

13. During the past month, how often did you feel
there were people you were close to?
{ Always
{ Very often
{ Sometimes
{ Almost never
{ Never

18. Did the personal stories and examples in the
BFWHW Emotional Wellness Guide seem
familiar to you or relate to your own life?
{ Yes, very related
{ Somewhat related
{ Not related at all
{ Unsure

14. Have you been given a copy of the BFWHW
Emotional Wellness Guide (either the Young
Women’s or the
Women’s Guide)?
{ Yes
{ No
{ Unsure

19. Would you share or recommend the BFWHW
Emotional Wellness Guide to friends or family
members?
{ I would recommend it to a friend or family
member
{ I would not recommend it to a friend or family
member
{ Unsure

If you answered
Yes to Question
#14, please
answer the rest of
the questions on
this survey.
If you answered “No” or “Unsure” to Question
#14, please only answer Question #22.

20. Now that you have been given the BFWHW
Emotional Wellness Guide, are you more or less
likely to talk about your emotional health and
well-being with your doctor, counselor or another
health care provider?
{ More likely
{ Less likely
{ No difference
{ Unsure

15. Did you read all or part of the BFWHW Emotional
Wellness Guide?
21. Please write down any other comments you have
{ All of it
about the BFWHW Emotional Wellness Guide
{ Part of it
that you would like to share:
{ Just skimmed it
____________________________________________
{ No
____________________________________________
____________________________________________
16. How easy is the BFWHW Emotional Wellness
____________________________________________
Guide to read and understand?
____________________________________________
{ Very easy
____________________________________________
{ Somewhat easy
{ Somewhat hard
22. Would you be interested in more information
{ Very hard
about how to improve your emotional health and
{ Not sure
well-being?
{ Yes
{ No

Thank you for your participation!
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 currently 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 15 minutes 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.