Delaware Self-Management Program Registration and Pre-Survey

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 6 week program has ended. Thank you!

Registration

Please enter the following information to register

Please list your email or a family member/friend’s email who will receive emails for you.

Phone
Have you ever used video conferencing?*

(Webex, Zoom, Facetime, or Skype)

How did you hear about this class?*

Select the most appropriate reason you decided to register

Delaware Self-Management Program Pre-Survey

Please fill out the following information.

__ years

Are you:*
Ethnicity*

What is your race? Please select all that apply

Are you deaf or do you have difficulty hearing?*
Are you blind or do you have serious difficulty seeing, even when wearing glasses?*
Do you live alone?*
What is the highest grade or year of school you completed?*
Have you ever served in the military?*
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?*
In general, would you say that your health is:*

Has a health care provider ever told you that you have any of the following chronic conditions? Please select all that apply

Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor's office or shopping?*
Do you have serious difficulty concentrating, remembering, or making decisions?*
Do you have a serious difficulty walking or climbing stairs?*
Do you have difficulty dressing or bathing?*
How often do you feel lonely or isolated from those around you?*
How sure are you that you can manage your condition so you can do the things you need and want to do?*

(1 - Totally unsure, 10 - Totally sure)

What is your primary language?*
What is your primary health care insurance?*
Smoking (check one)*
Physical activity*

Do you do any of the following: (walking, strengthening exercises, swimming, bicycling, aerobic exercise)

Little interest or pleasure in doing things?*

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

Feeling down, depressed or hopeless?*

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

Have you visited either in the last month?*
Pain level*

(0 - no pain, 10 - worst pain)

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