STEP Post Survey

Form Approved

OMB No. 0990-0379

Exp. Date 09/30/2019

Post-Survey

Date: _________________ Location: __________________________

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

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

2. Has Yoga helped to reduce any physical or chronic pain that you suffer from?

1 – Yes 2 – No

3. Has Yoga helped to reduce any emotional pain that you suffer from?

1. Yes 2 – No

4. Do you practice Yoga outside of the normal weekly class now?

1. – Yes 2– No 3– Sometimes

5. Did the STEP Yoga program allow you to meet new people and connect with others?

1 – Yes 2 – No

6. Do you feel more “educated” to make decisions about your overall healthcare?

1. – Yes 2 – No 3 - I feel the same as before

7. Do you feel more “empowered” to talk to your doctor and/or pharmacist?

1 – Yes 2 – No 3 – I feel the same as before

8. Do you believe that “breathing” and “mind/body activities” can help reduce pain?

1 – Yes 2 – No

9. Do you know how to properly dispose of old and unused medications?

1 – Yes 2 – No

10. Do you believe that there are alternative options to talking an opioid prescription pain medicine?

1 – Yes 2 – No

11. Do you believe Yoga can help reduce pain?

1. Yes 2 - No

12. Did STEP inspire you to focus more on your personal wellness?

1. Yes 2 - No

13. Did STEP inspire you to encourage your family to focus more on their health?

1. Yes 2 - No

14. Would you participate in STEP Yoga again?

1 – Yes 2 – No

15. Any suggestions to improve the class?

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Thank You!

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 ___ 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