Our practice is interested in the health habits of patient as part of a quality improvement project. We appreciate your taking 5 minutes to answer these questions about yourself. Please do not put your name on this survey. Completing this survey is voluntary.
For each question please check or circle the response that is most appropriate for you.
Thank you!
Section 1: Health and Health Behaviors
1. Would you say that in general your health is:
| ___ 1 Poor | ___ 2 Fair | ___ 3 Good | ___ 4 Very Good | ___ 5 Excellent |
2. How many of the past 7 days did you follow a healthful eating plan? ______ Days
3. In a typical day, how many servings of fruit and vegetables do you eat?
A serving is 1 banana, one apple, ½ cup of fruit juice, ten baby carrots, or one tomato.
- Fruit = ________ servings per day
- Vegetables = ________ servings per day
4. In the past month, how common was it for you or anyone in your family to go hungry because there was not have enough money for food?
| ___ 1 Very Common | ___ 2 Somewhat Common | ___ 3 Neutral | ___ 4 Uncommon | ___ 5 Very Uncommon |
5. Which statement best describes your usual exercise routine (by regular exercise, we mean spending at least 30 minutes on an activity that increases your heart rate outside of work-related activities, such as brisk walking, jogging, swimming, playing soccer or other sport or aerobics) (choose one):
___ 1 I do not exercise regularly.
___ 2 I exercise 1-2 times per week.
___ 3 I exercise 3-5 times per week.
___ 4 I exercise more than 5 times per week
6. Which statement best describes routine physical activity you undertake as part of your work (by routine physical activity as part of your work, we mean spending at least 30 minutes on an activity, such as digging, heavy lifting, heavy yard work) (choose one):
___ 1 My work does not involve routine physical activity.
___ 2 My work involves physical activity 1-2 times per week.
___ 3 My work involves physical activity 3-5 times per week.
___ 4 My work involves physical activity more than 5 times per week.
7. Do you have a disability that affects your ability to be physically active?
___ 1 No ___ 2 Yes
8. Are you currently making efforts to:
| Yes, I have been for more than 6 months. | Yes, I have been for less than 6 months. | No, but I intend to in the next 30 days. | No, but I intend to in the next 6 months. | No, and I do not intend to in the next 6 months. | |
|---|---|---|---|---|---|
| a. lose weight? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
| b. make healthy food choices? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
| c. be physically active on a regular basis? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
Section 2: Weight Status
9. When you consider your current body weight, do you consider yourself to be:
| ___ 1 Very Underweight | ___ 2 Somewhat Underweight | ___ 3 A Healthy Weight | ___ 4 Somewhat Overweight | ___ 5 Very Overweight |
Section 3: Community Weight Management Resources
10. Are there places in your community or nearby to assist adults with weight loss (e.g., diet programs, physical activity centers, etc.)?
___ 1 No
___ 2 I don't know/unsure
___ 3 Yes. Please specify what/where:
11. Are there places in your community or nearby to assist kids with weight loss (e.g., diet programs, physical activity centers, etc.)?
___ 1 No
___ 2 I don't know/unsure
___ 3 Yes. Please specify what/where:
12. Considering where you live, how easy is it for you to find locations to:
| Very Difficult | Somewhat Difficult | Easy | Very Easy | |
|---|---|---|---|---|
| a. get fruit to eat? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
| b. get vegetables to eat? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
| c. obtain fast food? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
| d. exercise in a gym? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
| e. play at a park? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
| f. use walking trails or bike paths? | ___ 1 | ___ 2 | ___ 3 | ___ 4 |
Section 4: Primary Care and Health Behavior Change
13. In the last year, how often has your primary care clinician talked with you about your:
| Never | Rarely | Sometimes | Frequently | Very Frequently | |
|---|---|---|---|---|---|
| a. weight? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
| b. diet? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
| c. physical activity? | ___ 1 | ___ 2 | ___ 3 | ___ 4 | ___ 5 |
14. Would you be interested in getting help from your doctor/clinic to connect with resources for weight management in your community?
| ___ 1 Not Very Interested | ___ 2 Somewhat Interested | ___ 3 Interested | ___ 4 Very Interested | ___ 5 Not Applicable |
15. What factors would affect your willingness to access resources for weight management in your community or nearby?
___ 1 Cost
___ 2 Time
___ 3 Transportation
___ 4 Quality of Resource
___ 5 Family Support
___ 6 Friend Support
___ 7 Clinic Support
___ 8 Confidentiality
___ 9 Other. Please specify:________________________________________________
16. What role should your doctor/clinic play in supporting weight loss efforts? (Check all that apply.)
___ 1 No role. This is not a responsibility I expect from my doctor.
___ 2 Screen patients for weight status during clinic visits.
___ 3 Ask patients about their interest in weight loss during clinic visits.
___ 4 Advise patients about the risks of overweight and obesity.
___ 5 Assess patients' willingness to make weight related health behavior changes.
___ 6 Assist patients in developing weight loss plans.
___ 7 Arrange referrals with community resources for weight management.
___ 8 I don't know/unsure.
___ 9 Other. Please comment:
Section 5: Demographics
17. Are you male or female? ___ 1 Male ___ 2 Female
18. What is your age? ________ Years of Age
