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Appendix C: Stanford Patient Education Chronic Disease Sample Questionnaire

Design and Evaluation of Three Administration on Aging (AoA) Programs: Chronic Disease Self-Management Program Evaluation Design—Final Evaluation Design Report (continued)

Name: _________________________________________________________

Today's date: ____________________________________________________

Address: ________________________________________________________

City, state, zip: ___________________________________________________

Telephone: home (______) ______ - ______; work (______) ______ - ______

Date of birth: ____________________________________________________

Sex (circle): Female      Male

Background

1. Ethnic origin (check only one):

___ White not Hispanic
___ Black not Hispanic
___ Hispanic
___ Asian or Pacific Islander
___ Filipino
___ American Indian/Alaskan Native
Other: __________________________

2. Please circle the highest year of school completed:

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23+
(primary) (high school) (college university) (graduate school)  

3. Are you currently (check only one):

___ Married
___ Single
___ Separated
___ Divorced
___ Widowed

4. Please indicate below which chronic condition(s) you have:

___ Diabetes
___ Asthma
___ Emphysema or COPD
___ Other lung disease Type of lung disease: _________________________________________________
___ Heart disease Type of heart disease: _________________________________________________
___ Arthritis or other rheumatic disease Specify type: _________________________________________________
___ Cancer Type of cancer: _________________________________________________
___ Other chronic condition Specify: _________________________________________________

General Health

1. In general, would you say your health is: (Circle one)

Excellent = 1
Very good = 2
Good = 3
Fair = 4
Poor = 5

Symptoms

How much time during the past 2 weeks...

  None of the time A little of the time Some of the time A good bit of the time Most of the time All of the time
1. Were you discouraged by your health problems? 0 1 2 3 4 5
2. Were you fearful about your future health? 0 1 2 3 4 5
3. Was your health a worry in your life? 0 1 2 3 4 5
4. Were you frustrated by your health problems? 0 1 2 3 4 5

1. We are interested in learning whether or not you are affected by fatigue. Please circle the number below that describes your fatigue in the past 2 weeks:

Checking the fatigue level in the past 2 weeks

2. We are interested in learning whether or not you are affected by shortness of breath. Please circle the number below that describes your shortness of breath in the past 2 weeks:

Checking shortness of breath in the past 2 weeks

3. We are interested in learning whether or not you are affected by pain. Please circle the number below that describes your pain in the past 2 weeks.

Checking the pain level in the past 2 weeks

Physical Activities

During the past week, even if it was not a typical week for you, how much total time (for the entire week) did you spend on each of the following? (Please circle one number for each question.)

  none less than 30 min/wk 30-60 min/wk 1-3 hrs per week more than 3 hrs/wk
1. Stretching or strengthening exercises (range of motion, using weights, etc.) 0 1 2 3 4
2. Walk for exercise 0 1 2 3 4
3. Swimming or aquatic exercise 0 1 2 3 4
4. Bicycling (including stationary exercise bikes) 0 1 2 3 4
5. Other aerobic exercise equipment (Stairmaster, rowing, skiing machine, etc.) 0 1 2 3 4
6. Other aerobic exercise

Specify_________________________

 0 1 2 3 4

Confidence About Doing Things

For each of the following questions, please circle the number that corresponds with your confidence that you can do the tasks regularly at the present time.

How confident are you that you can...

  not at all confident totally confident
1. Keep the fatigue caused by your disease from interfering with the things you want to do? 1 2 3 4 5 6 7 8 9 10
2. Keep the physical discomfort or pain of your disease from interfering with the things you want to do? 1 2 3 4 5 6 7 8 9 10
3. Keep the emotional distress caused by your disease from interfering with the things you want to do? 1 2 3 4 5 6 7 8 9 10
4. Keep any other symptoms or health problems you have from interfering with the things you want to do? 1 2 3 4 5 6 7 8 9 10
5. Do the different tasks and activities needed to manage your health condition so as to reduce your need to see a doctor? 1 2 3 4 5 6 7 8 9 10
6. Do things other than just taking medication to reduce how much your illness affects your everyday life? 1 2 3 4 5 6 7 8 9 10

Daily Activities

During the past 2 weeks, how much... (Circle one)

  Not at all Slightly Moderately Quite a bit Almost totally
1. Has your health interfered with your normal social activities with family, friends, neighbors or groups? 0 1 2 3 4
2. Has your health interfered with your hobbies or recreational activities? 0 1 2 3 4
3. Has your health interfered with your household chores? 0 1 2 3 4
4. Has your health interfered with your errands and shopping? 0 1 2 3 4

Medical Care

1. When you visit your doctor, how often do you do the following (please circle one number for each question):

  Never Almost never Sometimes Fairly often Very often Always
a. Prepare a list of questions for your doctor 0 1 2 3 4 5
b. Ask questions about the things you want to know and things you don't understand about your treatment 0 1 2 3 4 5
c. Discuss any personal problems that may be related to your illness 0 1 2 3 4 5

2. In the past 6 months, how many times did you visit a physician? Do not include visits while in the hospital or the hospital emergency department. __________ visits

3. In the past 6 months, how many times did you go to a hospital emergency department? __________ times

4. In the past 6 months, how many TIMES were you hospitalized for one night or longer? __________ times

a. How many total NIGHTS did you spend in the hospital in the past 6 months? __________ nights

b. Were any of these hospitalizations at a skilled nursing facility, convalescent hospital, or other minimum care facility? (circle)      Yes        No

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Page last reviewed December 2014
Page originally created May 2011
Internet Citation: Appendix C: Stanford Patient Education Chronic Disease Sample Questionnaire. Content last reviewed December 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/final-reports/aoa/aoachronic-apc.html

The information on this page is archived and provided for reference purposes only.

 
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