New Jersey Department of Health

Office of Minority and Multicultural Health

Chronic Disease Self-Management Program

“TAKE CONTROL OF YOUR HEALTH”

PRE-WORKSHOP PARTICIPANT SURVEY

ID Number:
Date:
Zip Code:
Sex (Check):	Female Male

What is your age group?

Under 25

25 - 34

35 - 44

45 - 54

55 - 64

65+

Are you Hispanic, Latino/a, or Spanish origin?

(One or more categories may be selected.)

a. Mexican, Mexican American, Chicano/a

b. Puerto Rican

c. Cuban

d. Another Hispanic, Latino, or Spanish origin

What is your race?

(One or more categories may be selected)

a.	White

b.	Black or African American

c.	American Indian or Alaska Native

d.	Asian Indian

e.	Chinese

f.	Filipino

g.	Japanese

h.	Korean

i.	Vietnamese

j.	Other Asian

k.	Native Hawaiian

l.	Guamanian or Chamorro

m.	Samoan

n.	Other Pacific Islander

Are you currently:

(check only one)

Married

Single

Separated

Divorced

Widowed

Partnered (living with someone)

What level of education did you complete?

(check only one)

Less than high school

Some high school

High school graduate

Some college or vocational school

College graduate

Graduate school

How well do you speak English? (check only one)

Very well Well Not well Not at all

Has a doctor or nurse ever told you that you are sick because you have:

(Mark all that apply.)
Arthritis/Rheumatic Disease

Breathing/ Lung Disease (e.g., Asthma, Emphysema, Bronchitis)

Diabetes

Heart Disease

Hypertension (High Blood Pressure)	Cancer

Stroke

Depression or Anxiety Disorder

Osteoporosis

Other Chronic Condition: _____________

None (No Chronic Conditions)

I. In general, would you say your health is: (check one)

Excellent Very Good Good Fair Poor

II. Daily Activities	(Circle one)
Not at all	Slightly	Moderately	Quite a bit	Almost totally
1	During the past 2 weeks, how much has your sickness stopped you from being with family, friends, neighbors or groups?	0	1	2	3	4
2	During the past 2 weeks, how much has your sickness stopped you from doing things you enjoy like reading, playing sports or other fun things?	0	1	2	3	4
3	During the past 2 weeks, how much has your sickness stopped you from doing everyday work around your house (e.g. cleaning, cooking etc.)?	0	1	2	3	4
4	During the past 2 weeks, how much has your sickness stopped you from doing other things that you need to do such as shopping?	0	1	2	3	4

III.	Controlling My Sickness

For each of the following questions, please circle one number for each question that tells how you feel about doing things easily at this time:	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1	Feeling tired from being sick does not stop me from doing things that I want to do.	1	2	3	4	5
2	Feeling pain, aches, or hurting from being sick does not stop me from doing things I want to do.	1	2	3	4	5
3	Feeling upset, sad, or crying from being sick does not stop me from doing things I want to do.	1	2	3	4	5
4	Feeling any other signs of sickness or health problems (aches, pains, or being sad) does not stop me from doing things I want to do.	1	2	3	4	5
5	I can do things I need to do to control my sickness so that I don’t go to the ER or ask to see my doctor.	1	2	3	4	5
6	I can do things other than just take a pill to stop my sickness from being a problem every day.	1	2	3	4	5

IV. During the past week I was able to stretch, walk, swim, bike, or do other types of exercise for:

(check only one)

None

Less than 30 minutes/week

30 - 60 minutes/week

1 – 3 hours/week

More than 3 hours/week

V.	Medical Care

When you go to your doctor:

(please circle one number for each question)	(Circle one)
Never	Almost never	Some-times	Fairly often	Very often	Always
1	Do you make a list of questions for your doctor?	0	1	2	3	4	5
2	Do you ask questions about the things you want to know and things you don’t understand?	0	1	2	3	4	5
3	Do you talk about things other than your being sick?	0	1	2	3	4	5
4	In the past 2 months, how many TIMES did you visit a doctor?

(Do not include hospital or ER visits)	________ times
5	In the past 2 months, how many TIMES did you go to a walk-in-clinic for an emergency?	________ times
6	In the past 2 months, how many TIMES did you go to a hospital emergency room?	________ times
7	In the past 2 months, how many TIMES were you admitted to the hospital for one night or longer?	________ times

VI. Check all that apply:

I am a member with a sickness.	Yes	No

I take care of someone with a sickness.	Yes	No

VII. Have you ever taken this class before?

Yes No Unsure

VIII. This survey was completed: (check only one)

Without help With some help
Thank you for completing the survey!

“TAKE CONTROL OF YOUR HEALTH”

PRE-WORKSHOP PARTICIPANT SURVEY

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