Chronic Pain Client Enrollment Survey-2021

Welcome! Please take this enrollment form Chronic Pain Self Management 2021 Spring

These programs are sponsored by the Administration for Community Living and we would like to collect some information to evaluate the effectiveness of the programs. If you wish to leave a question blank, you may. The page will refresh and warn you that a question was not completed. Simply click 'Next' again and you will be taken to the next page in the survey. All data is encrypted and stored securely.

What is your name? *This question is required.

Last
First

1. Nick name you'd like be called in class

Email Address *This question is required. This question requires a valid email address.

Phone Number *This question is required.

Home Address (for mailing)

Address
City
Zipcode

2. Which class you are you signing for?

The Tuesday Feb class is full. We scheduled a class starting in March 10 at 9:30 am on Wednesday *This question is required.

3. Did your doctor or other health care provider suggest you attend this program?

Yes	No
Yes	No

4. How old are you today? (years) This question requires a valid number format.

5. Are you_______

6. Are you of Hispanic, Latino, or Spanish origin?

7. What is your race / ethnicity?

American Indian or Alaskan Native
Asian
Black or African American

Native Hawaiian or other Pacific Islander
White

8. Please answer the following questions:

Space Cell	Yes	No
Are you deaf or do you have serious hearing difficulty?	Are you deaf or do you have serious hearing difficulty?: Yes	Are you deaf or do you have serious hearing difficulty?: No
Are you blind or do you have serious difficulty seeing, even when wearing glasses?	Are you blind or do you have serious difficulty seeing, even when wearing glasses?: Yes	Are you blind or do you have serious difficulty seeing, even when wearing glasses?: No
Do you live alone?	Do you live alone?: Yes	Do you live alone?: No
Have you ever served in the military?	Have you ever served in the military?: Yes	Have you ever served in the military?: No
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?	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	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?: No

9. What is the highest grade or year of school you completed?

Some elementary, middle, or high school	High school graduate or GED	Some college or technical school	College 4 years or more
Some elementary, middle, or high school	High school graduate or GED	Some college or technical school	College 4 years or more

10. In general, would you say your health is:

Excellent	Very Good	Good	Fair	Poor
Excellent	Very Good	Good	Fair	Poor

11. Please indicate if a healthcare provider has ever told you that you have any of the following chronic conditions:

Schizophrenia or other Psychotic Disorder
Stroke
Arthritis / Rheumatic Disease
Other Chronic Condition

12. Please answer the following questions:

Space Cell	Yes	No
Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?: Yes	Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?: No
Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shop?	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shop?: Yes	Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shop?: No
Do you have difficulty walking on stairs?	Do you have difficulty walking on stairs?: Yes	Do you have difficulty walking on stairs?: No
Do you have difficulty dressing or bathing?	Do you have difficulty dressing or bathing?: Yes	Do you have difficulty dressing or bathing?: No

13. How often do you feel lonely or isolated from those around you?

Always	Often	Sometimes	Rarely	Never
Always	Often	Sometimes	Rarely	Never

14. What is your health insurance coverage?

Please enter an 'other' value for this selection.

15. What is your level of confidence in managing your chronic condition(s)? (Please circle one number.)

	0	1	2	3	4	5	6	7	8	9	10
Not at all confident	0	1	2	3	4	5	6	7	8	9	10	Very Confident

16. In the past week, did you ever forget to take your medicine?

Yes	No	I don't need to take medications
Yes	No	I don't need to take medications

17. In the past week, how many days did you exercise for at least 30 minutes? (Please circle one number.)

0 day

3/4 times a week

7 days of the week

18. How often do you examine Nutrition Facts labels to aid in making food choices? (Please circle one number.)

Never	Occasionally	About half time	Usually	Always
Never	Occasionally	About half time	Usually	Always

19. When you visit your doctor, nurse or other health care provider, how often do you prepare a list of questions? (Please circle one number.)

Never	Occasionally	About half time	Usually	Always
Never	Occasionally	About half time	Usually	Always

Chronic Pain Client Enrollment Survey-2021

Chronic Pain Self Management Client Enrollment