View source for Well-Being Assessment

The [[Well-Being Assessment]] is a [[Patient Assessments|patient assessment]] designed to capture patient information with the goal of improving the patient's overall health and well-being. It captures the patient's [[determinants]], [[Patient Barriers|barriers]] and [[symptoms]].

'''Physical Activity''' <br> 	
[[Q1|1.]] In the past 7 days, how many days did you exercise? <br> 
□ 6 or 7 days <br>     
□ 4 or 5 days <br>   
□ 2 or 3 days <br> 
□ 1 day <br>    
□ none

'''Tobacco Use''' <br> 	
[[Q4|4.]] In the last 30 days, have you used tobacco? □ yes  □ no		

'''Alcohol Use''' <br> 	
[[Q7|7.]] In the past 7 days, how many days did you drink alcohol? <br> 	
□ 6 or 7 days <br>     
□ 4 or 5 days <br>   
□ 2 or 3 days <br> 
□ 1 day <br>    
□ none	

'''Nutrition'''	<br> 
[[Q10|10.]] In the past 7 days, how many servings of fruit and vegetables do you eat per day? <br>	
(1 serving = 1 cup fresh vegetables, ½ cup cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball) <br>
□ 6 or more servings per day <br>     
□ 4 or 5 servings per day <br>   
□ 2 to 3 servings per day <br> 
□ 1 serving per day <br>    
□ none

[[Q11|11.]] In the past 7 days, how many servings of high fiber or whole grains food do you eat per day? <br>	
(1 serving = 1 slice of 100% whole wheat bread, 1 cup of whole-grain or high-fiber ready-to-eat cereal,  ½ cup of cooked cereal such as oatmeal, or ½ cup of brown rice or whole wheat pasta) <br>
□ 6 or more servings per day <br>     
□ 4 or 5 servings per day <br>   
□ 2 to 3 servings per day <br> 
□ 1 serving per day <br>    
□ none

[[Q12|12.]] In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day? <br> 	
(Examples include fried chicken, fried fish, bacon, french fries, potato chips, corn chips, doughnuts, creamy salad dressing, and foods made with milk, cream, cheese, or mayonnaise.) <br>
□ 6 or more servings per day <br>     
□ 4 or 5 servings per day <br>   
□ 2 to 3 servings per day <br> 
□ 1 serving per day <br>    
□ none

[[Q13|13.]] In the past 7 days, how many ''sugar-sweetened'' (not diet) beverages did you consume each day? <br>
□ 6 or more servings per day <br>     
□ 4 or 5 servings per day <br>   
□ 2 to 3 servings per day <br> 
□ 1 serving per day <br>    
□ none

'''Depression''' <br> 	
[[Q15|15.]] In the past 2 weeks, how often have you been felt down, depressed, or hopeless? <br>	
□ Nearly every day <br>     
□ More than half the days <br>   
□ Several days <br>    
□ Not at all	

[[Q16|16.]] In the past 2 weeks, how often have you felt little interest or pleasure in doing things? <br>
□ Nearly every day <br>     
□ More than half the days <br>   
□ Several days <br>    
□ Not at all	

'''Anxiety''' <br> 
[[Q18|18.]] In the past 2 weeks, how often have you felt nervous, anxious, or on edge? <br>	
□ Nearly every day <br>     
□ More than half the days <br>   
□ Several days <br>    
□ Not at all

[[Q19|19.]] In the past 2 weeks, how often were you not able to stop worrying or control your worrying? <br>
□ Nearly every day <br>     
□ More than half the days <br>   
□ Several days <br>    
□ Not at all	

'''Stress''' <br> 	
[[Q20|20.]] How often is stress a problem for you in handling such things as: <br>
- Your health? <br>
- Your finances? <br>
- Your family or social relationships? <br>
- Your work? <br>	
□ Never or rarely <br>   
□ Sometimes <br>    
□ Often <br>    
□ Always 	

'''Social/Emotional Support''' <br> 
[[Q21|21.]] How often do you get the social and emotional support you need: <br>	
□ Always <br>   
□ Usually <br>   
□ Sometimes <br>    
□ Rarely <br>     
□ Never 	
	
'''Pain''' <br>  	
[[Q22|22.]] In the past 7 days, how much pain have you felt? <br>    	
□ None <br>        
□ Some <br>       
□ A lot    	
	
'''General Health''' <br> 	
[[Q23|23.]] In general, would you say your health is <br>	
□ Excellent <br>     
□ Very Good<br>     
□ Good <br>     
□ Fair <br>    
□ Poor 

[[Q24|24.]] How would you describe the condition of your mouth and teeth - including false teeth or dentures? <br>  	
□ Excellent <br>     
□ Very Good<br>     
□ Good <br>     
□ Fair <br>    
□ Poor 	

'''Activities of Daily Living''' <br> 	
[[Q25|25.]] In the past 7 days, did you need help from others to perform everyday activities such as eating, getting dressed, grooming, bathing, walking or using the toilet? <br> 
□ yes  □ no 	
	
'''Instrumental Activities of Daily Living'''<br>  	
[[Q26|26.]] In the past 7 days, did you need help from others to take care of things such as laundry and housekeeping, banking, shopping, using the telephone, food preparation, transportation or taking your medications? <br> 
□ yes  □ no 	
	
'''Sleep''' <br> 	
[[Q27|27.]] Each night, how many hours of sleep do you usually get? <br>   	
□ 10 or more hours per day <br>     
□ 8 or 9 hours per day <br>   
□ 6 or 7 hours per day <br> 
□ 4 or 5 hours per day <br>    
□ Less than 4

[[Q29|29.]] In the past 7 days, how often have you felt sleepy during the daytime? <br>	
□ Always <br>   
□ Usually <br>   
□ Sometimes <br>    
□ Rarely <br>     
□ Never 

'''Blood Pressure - Self Reported''' <br> 
[[Q30|30.]] If your blood pressure was checked ''within the past year'', what was it when it was last checked? <br>   	
□ Low or normal (at or below 120/80) <br>   
□ Borderline high (120/80 to 139/89) <br>    
□ High (140/90 or higher) <br>   
□ Don't know/not sure
	
'''Cholesterol - Self Reported''' <br> 	
[[Q31|31.]] If your cholesterol was checked ''within the past year'', what was it when it was last checked? <br>   
□ Desirable (below 200) <br>
□ Borderline high (200-239) <br>
□ High (240 or higher) <br>
□ Don't know/not sure
	
'''Blood Glucose - Self Reported''' <br> 	
[[Q32|32.]] If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked? <br> 	
□ Desirable (below 100)<br>
□ Borderline high (100-125)<br>
□ High (126 or higher)<br>
□ Don't know/not sure

'''Fall Risk''' <br> 	
[[Q40|40.]] How many time have you fallen in the past 12 months? <br> 	
□ more than 10 times <br>     
□ 5 to 10 times <br>   
□ 2 to 5 times <br> 
□ 1 times <br>    
□ none	

'''Cognitive''' <br> 	
[[Q41|41.]] In the past 7 days, I've had instances when I have forgotten things that recently happened <br>
□ More than 10 times<br>
□ 3 to 10 times<br>
□ Once or twice<br>
□ None

'''Resilience'''<br>
[[Q42|42.]] All things considered, are you satisfied with each of the following (Please check each):<br>
□ Emotional fitness - ability to manage positive and negative emotions in a constructive way <br>
□ Social fitness - trust, friendships, balance between social/privacy and social/loneliness <br>
□ Family fitness - trust, friendship, intimacy, supportive dialog, manage conflict, avoid escalation<br>
□ Spiritual fitness - positive levels of purpose and meaning through religious or non-religious means<br> 
□ Overall Life Satisfaction 

'''Purpose, Meaning & Goals''' <br>  	
[[Q43|43.]] My health conditions do not prevent me from pursuing my passions or what provides me purpose and meaning in my life?<br>   	
□ Agree <br>
□ Somewhat Agree<br>
□ Disagree

'''Patient Activation''' <br> 	
[[Q44|44.]] I fully understand my chronic conditions (i.e, asthma, high blood pressure), their potential risks and how they can be managed? <br>
□ Agree <br>
□ Somewhat Agree<br>
□ Disagree

[[Q45|45.]] I am confident I can self-manage my chronic conditions to prevent them from worsening or impacting my well-being? <br>	
□ Agree <br>
□ Somewhat Agree<br>
□ Disagree

'''Support'''<br>	
[[Q46|46.]] In the past year, my family has provided physical and emotional support when I needed it <br>	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never 

[[Q47|47.]] In the past year, I suffered through health conditions, medical concerns, or skipped medical treatments because I didn't have someone to help me?<br> 	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never 
   	
'''Responsibilities'''<br>	
[[Q48|48.]] I have responsibilities (i.e., children, sick parent, job) that I've had to put in front of my personal health in the past 12 months? <br> 	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never
	
'''Financial'''	<br>	
[[Q49|49.]] In the past year, I've experienced interruptions in nutritional food, medicine, or treatment due to financial constraints? <br>	 	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never

'''Access & Logistics'''<br>	
[[Q50|50.]] I have missed medical treatments (including medications) because I lacked transportation or it wasn't convenient enough? <br>		
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never 

'''Community'''<br>	
[[Q51|51.]] I feel safe walking on my street and through my neighborhood? <br>	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never

'''Home'''<br>	
[[Q52|52.]] In the past year, I have lived uninterrupted in a safe home with heat/ac, hot water, conducive to sleeping and no structural barrier (i.e., not wheel chair accessible)?<br>	   	
□ Always <br>
□ Usually <br>
□ Sometimes<br>
□ Rarely<br>
□ Never