Registration and Pre-Survey
Delaware Self-Management Program

As part of this program, we are asked to collect information about participants to see the effectiveness of the programs and ways we can improve our offerings. Most of the data is kept internally as per privacy laws. We send program information to the National Council on Aging (NCOA) for comparison with other like programs. The collected data will be used to determine if we are providing the most appropriate education to you and are able to change some of your health outcomes. We will collect this data at various time periods after this six-week program has ended through an online survey.

You are invited to participate in this online survey collected by the Delaware Self-Management Program (SMP). Agreeing to respond to the survey is completely voluntary and does not impact future participation in any SMP programming. Your responses will not be shared with anyone outside of the program, and your identity will be protected.

Thank you!

Registration

Registration

Please enter the following information to register

First Name

Last Name

Year of birth

Email Address

Please list your email or a family member/friend’s email who will receive emails for you. If there is no email or the participant is unable to participate in post surveys, please leave blank.

Mailing Address

City

Zip code

Phone

Phone

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

Yes

No

Delaware Self-Management Program Pre-Survey

Delaware Self-Management Program Pre-Survey

Please fill out the following information.

How old are you today?

__ years

Which of the following best represents how you think of yourself?

Select one

LGBTQIA+

Straight (that is, not LGBTQIA+)

I use a different term

Prefer not to answer

Ethnicity

Hispanic or Latino

Not Hispanic or Latino

What is your race? Please select all that apply

American Indian or Alaska Native

American Indian or Alaska Native

Asian

Asian

Black or African American

Black or African American

Native Hawaiian or other Pacific Islander

Native Hawaiian or other Pacific Islander

White

White

Do you have a disability?

Yes

No

Are you deaf or do you have difficulty hearing?

Yes

No

Are you blind or do you have serious difficulty seeing, even when wearing glasses?

Yes

No

Do you live alone?

Yes

No

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, four years or more

Have you ever served in the military?

Yes

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?

Yes

No

Has a health care provider ever told you that you have any of the following chronic conditions? Please select all that apply, or check None if you have never been told you had one of these chronic conditions.

Alzheimer's disease or dementia

Alzheimer's disease or dementia

Anxiety Disorder

Anxiety Disorder

Arthritis/Rheumatic Disease

Arthritis/Rheumatic Disease

Asthma/Emphysema/Other Chronic Breathing or lung problem

Asthma/Emphysema/Other Chronic Breathing or lung problem

Cancer or Cancer Survivor

Cancer or Cancer Survivor

Chronic Pain

Chronic Pain

Depression

Depression

Pre-diabetes

Pre-diabetes

Diabetes (High Blood Sugar)

Diabetes (High Blood Sugar)

Heart Disease

Heart Disease

High Cholesterol

High Cholesterol

Hypertension (High Blood Pressure)

Hypertension (High Blood Pressure)

Kidney Disease

Kidney Disease

Malnutrition

Malnutrition

Obesity

Obesity

Osteoporosis (Low Bone Density)

Osteoporosis (Low Bone Density)

Post-Traumatic Stress Disorder

Post-Traumatic Stress Disorder

Schizophrenia or Other Psychotic Disorder

Schizophrenia or Other Psychotic Disorder

Stroke

Stroke

Substance Use Disorder

Substance Use Disorder

Urinary Incontinence

Urinary Incontinence

None

None

Other Chronic Condition

Other Chronic Condition

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?

Yes

No

Do you have serious difficulty concentrating, remembering, or making decisions?

Yes

No

Do you have a serious difficulty walking or climbing stairs?

Yes

No

Do you have difficulty dressing or bathing?

Yes

No

What is your primary health care insurance?

Medicare

Medicaid

Private insurance

Uninsured

Smoking (check one)

Current smoker

Former smoker

Non-smoker

Physical activity

Do you do any type of physical activity (for example: walking, strengthening exercises, swimming, bicycling, aerobic exercise)?

Yes

No

How many minutes per week?

Little interest or pleasure in doing things?

In the last two weeks, how often have you been bothered?

Not at all (0)

Several days (1)

More than half the days (2)

All the days (3)

Feeling down, depressed or hopeless?

In the last two weeks, how often have you been bothered?

Not at all (0)

Several days (1)

More than half the days (2)

All the days (3)

Have you visited either in the last month?

Emergency Room

Hospital (as a patient)

Both

Neither

Weight

Last BP

If diabetic, last Hemoglobin A1c

Send me a copy of my responses

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