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

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.

Mailing Address

City

Zip code

Phone

Phone

Have you ever used video conferencing?

(Webex, Zoom, Facetime, or Skype)

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

Are you:

Male

Female

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

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 4 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

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

Obesity

Obesity

Osteoporosis (Low Bone Density)

Osteoporosis (Low Bone Density)

Schizophrenia or Other Psychotic Disorder

Schizophrenia or Other Psychotic Disorder

Stroke

Stroke

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 language?

English

Spanish

Korean

Chinese

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 of the following: (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

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