2 Participant Information Survey

Your Program Name
Participant Information Survey
Participant I.D. (first two letters of your first name, first two letters of your last
name, last two numbers of your birth year): __ __ __ __ __ __
1. How old are you today? ______ years
2. Are you: O Male or O Female?
3. Are you of Hispanic, Latino, or Spanish origin?
O Yes
O No
4. What is your race? Mark all that apply.
O
O
O
O
O

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific Islander
White

5. Has a health care provider ever told you that you have any of the following chronic
conditions? (Please mark all that apply.)
O Arthritis/Rheumatic Disease
O Asthma/Emphysema/Other Chronic
Breathing or Lung Problem
O Cancer or Cancer Survivor
O Chronic Pain
O Depression or Anxiety Disorders
O Diabetes (High Blood Sugar)
O Heart Disease
O High Cholesterol

O Hypertension (High Blood Sugar)
O Kidney Disease
O Osteoporosis (Low Bone Density)
O Obesity
O Schizophrenia or Other Psychotic
Disorder
O Stroke
O Other Chronic Condition
O None (No Chronic Conditions)

6. During the past year, did you provide regular care or assistance to a friend or
family member who has a long-term health problem or disability?
O Yes

O No
Please turn over

7. Are you deaf or do you have serious difficulty hearing?
O Yes
O No
8. Are you blind or do you have serious difficulty seeing even with glasses?
O Yes
O No
9. Because of a physical, mental, or emotional condition, do you have serious difficulty
walking or climbing stairs, dressing or bathing, or doing errands alone such as visiting a
doctor’s office or shopping?
O Yes
O No
10. Do you live alone? O Yes

O No

11. What is the highest grade or year of school you completed?
O Some elementary, middle, or high school
O High school graduate or GED
O Some college or technical school
O College 4 years or more
12. In general, would you say that your health is:
O Excellent

O Very good

O Good

O Fair

O Poor

13. Did your doctor or other health care provider suggest that you take this program?
O Yes
O No
______________________________________________________________________________

TO BE COMPLETED AT LAST PROGRAM SESSION
Please circle the number that best matches how confident you are feeling.
14. After taking this workshop, I am more confident that I can manage my chronic condition(s).

Not at all
Totally
1 2 3 4 5 6 7 8 9 10
confident
confident