Healthy Aging Toolkit - Synergy

Which program are you interested in attending? *This question is required.

• Chronic Condition Self-Management Program
• Diabetes Self-Management Program

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

• Yes
• No

13. What is your gender?

• Male
• Female

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

• Yes
• No
• Unknown

15. What is your race?

• American Indian or Alaska Native
• Asian or Asian-American
• Black or African American
• Hawaiian Native or Pacific Islander
• White or Caucasian
• Other Please enter an 'other' value for this selection. * This question is required.

16. Are you deaf or do you have serious difficulty hearing?

• Yes
• No

17. Are you blind or do you have serious difficulty seeing even with glasses?

• Yes
• No

18. Do you live alone? 

• Yes
• No

19. What is your marital status?

• Married
• Single
• Separated
• Divorced
• Widowed

20. Please select your highest level of education.

• Less than high school
• Some high school
• High school graduate or GED
• Some college or vocational school
• College graduate or higher

21. Have you ever served in the military?

• Yes
• No

22. 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

23. In general, would you say that your health is:  *This question is required.

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

24. Has a healthcare provider ever told you that you have any of the following chronic conditions? (Select all that apply)

• Arthritis or other bone/joint problem
• Breathing/lung disease (asthma, emphysema, bronchitis)
• Cancer or cancer survivor
• Chronic pain
• Depression or anxiety disorder
• Prediabetes
• Type 1 diabetes
• Type 2 diabetes
• Heart disease
• High cholesterol
• High blood pressure (hypertension)
• Kidney disease
• Low bone density (osteoporosis)
• Obesity
• Schizophrenia or other psychotic disorder
• Stroke
• Other chronic conditions - Write In (Required) Please enter an 'other' value for this selection. * This question is required.
• None (no chronic conditions)

25. Because of a physical, mental or emotional condition, do you have serious difficulty with the following?

• concentrating, remembering or making decisions
• doing errands alone such as visiting the doctor's office or shopping
• dressing or bathing
• walking or climbing stairs
• none of the above

26. How often do you feel isolated from others?

• Always
• Often
• Sometimes
• Rarely
• Never

27.  How confident are you that you can manage your long term health conditions? 
  *This question is required.

	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	Totally confident

28. How confident are you that you can keep the fatigue caused by your disease from interfering with the things you want to do? 

	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	Totally confident

29. How confident are you that you can keep the physical discomfort or pain caused by your disease from interfering with the things you want to do? 

	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	Totally confident

30. How confident are you that you can keep the emotional distress caused by your disease from interfering with the things you want to do? 

	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	Totally confident

31.  How confident are you that you can keep any other symptoms or health problems you have from interfering with the things you want to do? 

	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	Totally confident

32.  How confident are you that you can do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor? 
 

	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	Totally confident

33.  How confident are you that you can do things other than just taking medication to reduce how much your illness affects your everyday life? 
 

	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	Totally confident