Chronic Disease Research Study Survey
Obesity
Did you know that you can help prevent chronic disease? Obesity is a chronic disease and you can help prevent obesity! Education level, income and race are just a few factors that play a role in determining those at risk or have obesity and related conditions. A chronic disease is a condition that lasts 1 year or more, require ongoing medical attention, and/or limit activities of daily living. Chronic diseases, including obesity, are caused by a short list of risk behaviors such as : tobacco use and exposure to secondhand smoke, poor nutrition, lack of physical activity, and excessive alcohol use.
Did you know that health-related smartphone apps are recommended to patients with obesity? Clinicians actually recommend smartphone aps for self-monitoring of dietary and physical activity behaviors.
As a research participant your interest and engagement is part of a creative solution to develop a public health informatics tool that can help everyone make healthy choices so that the likelihood of getting a chronic disease can be reduced and quality of life can be improved. This web based and mobile application for obesity intervention and healthy lifestyles program will send nutrition, physical activity level, sleep, and sitting time information to users and clinicians of their choice to adapt face-to-face obesity interventions for a mobile app and deliver secure and effective care remotely for all genders, adolescents, and adults in America.
Traditional methods for monitoring diet and physical activity behaviors are a thing of the past ! Your answers to this survey are confidential . Your answers will inform the creation of a web based and mobile tracking app that communicates important information to clinicians working in diabetes and weight management patient care settings to improve patient outcomes.
Demographics:
1. What was your sex at birth? Was it…
a) Male
b) Female
3. Are you Hispanic, Latino/a, or Spanish origin?
a) Yes
If yes, read: Are you…
a) Mexican, Mexican American, Chicano/a
b) Puerto Rican
c) Cuban
d) Another Hispanic, Latino/a, or Spanish origin
b) No
2. Which one or more of the following would you say is your race?
a. White
b. Black or African American
c. American Indian or Alaska Native
d. Asian
i. Asian Indian
ii. Chinese
iii. Filipino
iv. Japanese
v. Korean
vi. Vietnamese
vii. Other Asian
e. Pacific Islander
i. Native Hawaiian
ii. Guamanian or Chamorro
iii. Samoan
iv. Other Pacific Islander
3. What is your age? ________ years:
a) 12 – 17 years
b) 18 – 24 years
c) 25 – 34 years
d) 35 – 44 years
e) 45 – 54 years
f) 55 – 64 years
g) 65 – 74 years
h) 75 years or above
i) Prefer not to say
4. Education (highest degree completed):
a) Never attended school or only attended kindergarten
b) Grades 1 through 8 (Elementary)
c) Grades 9 through 11 (Some high school)
d) Grade 12 or GED (High school graduate)
e) College 1 year to 3 years (Some college or technical school)
f) College 4 years or more
5. Which of these describes your personal income last year?
a) $0
b) $1 to $9 999
c) $10 000 to $24 999
d) $25 000 to 49 999
e) $50 000 to 74 999
f) $75 000 to 99 999
g) $100 000 to 149 999
h) $150 000 and greater
i) Prefer not to answer
9. What is the ZIP Code where you currently live?
_ _ _ _ _
6. Are you currently…?
a) Employed for wages
b) Self-employed
c) Out of work for 1 year or more
d) Out of work for less than 1 year
e) A Homemaker 6 A Student
f) Retired
g) Unable to work
7. About how much do you weigh without shoes?
_ _ _ _ Weight (pounds/kilograms)
8. About how tall are you without shoes?
_ _ / _ _ Height (ft / inches/meters/centimeters
9. Because of a physical, mental, or emotional condition, do you have difficulty doing errands alone such as visiting a doctor’s office or shopping?
a) Yes
b) No
c) Don’t know / Not sure
Health Status :
1. Would you say that in general your health is –
a) Excellent
b) Very Good
c) Good
d) Fair
e) Poor
Healthy Days :
1. Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?
_____ days (Enter a number between 01 – 30 )
2. Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?
_____ days (Enter a number between 01 – 30 )
3.. During the past 30 days, for about how many days did poor physical or mental health keep you from doing your usual activities, such as selfcare, work, or recreation?
_____ days (Enter a number between 01 – 30 )
Health Care Access
1. Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs, or government plans such as Medicare, or Indian Health Service?
a) Yes
b) No
c) Don’t know / Not sure
2. Was there a time in the past 12 months when you needed to see a doctor but could not because of cost?
a) Yes
b) No
c) Don’t know / Not sure
3. How your household usually travels to the store for your grocery shopping:
a) in my car
b) in a car that belongs to someone I live with
c) in a car that belongs to someone who lives elsewhere
d) walk
e) ride bicycle
f)bus, subway, or other public transit
g) taxi or other paid driver
h) taxi or other paid driver
i) someone else delivers groceries
3a. Grocery shopping center location types nearby , select all that apply:
a) Farmers Market
b) Convenience store (gas station)
c) Drug store
d) Grocery store
3b. How often do you eat fast food ?
a) Once a week
b)2-3 times a week
c) More than 3 times a week
3c. How many green servings of vegetables do you have daily?
a)1 serving a day
b)2 servings a day
c)3 or more servings a day
4. About how long has it been since you last visited a doctor for a routine checkup?
a) Within the past year (anytime less than 12 months ago)
b) Within the past 2 years (1 year but less than 2 years ago)
c) Within the past 5 years (2 years but less than 5 years ago)
d) 5 or more years ago
Exercise:
1. During the past month, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?
a) Yes
b) No
c) Don’t know / Not sure
Inadequate Sleep:
1. On average, how many hours of sleep do you get in a 24-hour period?
a) _ _ Number of hours [01-24]
b) Don’t know / Not sure
Chronic Health Conditions :
1. Has a doctor, nurse, or other health professional ever told you that you had any of the following? Select all that apply:
a) Coronary Heart Disease
b) Stroke
c) Asthma
d) Cancer (any type)
e) Chronic obstructive pulmonary disease, C.O.P.D., emphysema or chronic bronchitis
f) Some form of arthritis, rheumatoid arthritis, gout, lupus, or fibromyalgia
g) Depressive disorder (including depression, major depression, dysthymia, or minor depression)
h) Not including kidney stones, bladder infection or incontinence, were you ever told you have kidney disease?
i) Diabetes
Tobacco Use :
1. How long has it been since you last smoked a cigarette, even one or two puffs?
a) Within the past month (less than 1 month ago)
b) Within the past 3 months (1 month but less than 3 months ago)
c) Within the past 6 months (3 months but less than 6 months ago)
d) Within the past year (6 months but less than 1 year ago) 05 Within the past 5 years (1 year but less than 5 years ago)
e) Within the past 10 years (5 years but less than 10 years ago) 07 10 years or more 08 Never smoked regularly 77 Don’t know / Not sure
2. Do you currently use chewing tobacco, snuff, or snus every day, some days, or not at all?
a) Every day
b) Some days
c) Not at all
d) Don’t know / Not sure
Alcohol
1. During the past 30 days, how many days per week or per month did you have at least one drink of any alcoholic beverage such as beer, wine, a malt beverage or liquor?
a)_ _ Days per week
b) _ _ Days in past 30 days
c) No drinks in past 30 days
d) Don’t know / Not sure