Take Control of Your Health
Participant Information Survey
Instructions:

Please use a pen to answer the questions on both sides of this form.

Please print clearly. Mark your choice within the box, like this: X
Participant ID (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: Male or Female?
3.	Are you of Hispanic, Latino, or Spanish origin?
Yes	No
4.	What is your race? (Mark all that apply)
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)
Alzheimer’s or Related Dementia

Arthritis/Rheumatic Disease

Asthma/Emphysema/Other Chronic

Breathing or Lung Problem

Cancer or Cancer Survivor

Chronic Pain

Depression or Anxiety Disorders

Diabetes

Heart Disease

High Cholesterol

Hypertension (High Blood Pressure)

Kidney Disease

Obesity

Osteoporosis (Low Bone Density)

Schizophrenia or Other Psychotic

Disorder

Stroke

Other Chronic Condition:

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?
Yes	No
Please turn over ⇨

Participant Information Survey (Continued)
Participant ID
7.	Are you deaf or do you have serious difficulty hearing?
Yes	No
8.	Are you blind or do you have serious difficulty seeing even with glasses?
Yes	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?
Yes	No
10.	Do you live alone?
Yes	No
11.	What is the highest grade or year of school you completed?
Some elementary, middle or high school

High school or GED

Some college or technical school

College 4 years or more
12.	In general, would you say that your health is:
Excellent Very Good Good Fair Poor
13.	Did your doctor or other health care provider suggest that you take this program?
Yes	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
confident

1

2

3

4

5

6

7

8

9

10

Totally
confident

ACS-19

DEC 16	Page 2 of 2 Pages.

ACS-19, Participant Information Survey

ACS-19, participant information survey, take Control of Your Health, Aging and Community Services, ACS

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2016-12-21

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