FAMILY

During the past month, how often did you talk about your problems, feelings, or opinions with someone in your family?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

FAMILY

During the past month, how often did you talk about your problems, feelings, or opinions with someone in your family?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

During the past month, how often did you talk about your problems, feelings, or opinions with someone in your family?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

FAMILY

You answered that you rarely or never talked about problems, feelings, or opinions with someone in your family.

Have you talked to anyone about the family problem?

Yes

No

FAMILY

You answered that you talked to someone about the family problem.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

You answered that you talked to someone about the family problem.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

FEELINGS

During the past month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue?

None of the time
A little of the time
Some of the time
Most of the time
All of the time

You answered that you have been bothered more than average by your feelings.

Have you talked to anyone about your feelings?

Yes

No

 

You answered that you have talked to someone about your feelings.

Was what you were told helpful to you?

Extremely

Quite a lot

Moderately

A little

Not at all

FEELINGS

You answered that you have talked to someone about your feelings.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

HEALTH HABITS I

During the past month, how often did you do things that are harmful to your health such as smoke cigarettes or chew tobacco, have unprotected sex, or use alcohol including beer and wine?

None of the time
A little of the time
Some of the time
Most of the time
All of the time

You answered that you often do things that are harmful to your health.

Have you talked to anyone about these things?

Yes

No

HEALTH HABITS I

You answered that you talked with someone about your harmful health habits.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

HEALTH HABITS I

You answered that you talked with someone about your harmful health habits.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

PAIN

During the past month, how often were you bothered by pains such as backaches, headaches, cramps or stomach aches?

None of the time
A little of the time
Some of the time
Most of the time
All of the time

You answered that you had greater than average bodily pain.

Have you talked to anyone about your pain?

Yes

No

PAIN

You answered that you talked to someone about your bodily pain.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

You answered that you had greater than average bodily pain.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

During the past month, if you needed someone to listen or to help you, was someone there for you?

Yes, as much as I wanted
Yes, quite a bit
Yes, some
Yes, a little
No, not at all

You answered that you had very little or no social support.

Have you talked to anyone about this problem?

Yes

No

You answered that you talked to someone about your social support.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

You answered that you had very little or no social support.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

PHYSICAL FITNESS

During the past month, what was the hardest physical activity you could do for at least 10 minutes?

Very heavy
Heavy
Moderate
Light
Very light

PHYSICAL FITNESS

You answered that you had greater than average difficulty doing physical activities.

Have you talked to anyone about your physical fitness?

Yes

No

You answered that you talked to someone about your physical fitness.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

You answered that you talked to someone about your physical fitness.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

During the last month you were in school, how did you do?

I did very well
I did as well as I could
I could have done a little better
I could have done much better
I did poorly

You answered that you could have done better in school.

Have you talked to anyone about your school work?

Yes

No

You answered that you had talked to someone about your school work.

Was what you were told helpful for you?

Extremely

Quite a lot

Moderately

A little

Not at all

You answered that you had talked to someone about your school work.

Who were the people you spoke to? (Please mark all that apply)

Family

Friends

Doctors or nurses

Teachers or school counselors

Others

How often do you practice good health habits in two or more of the following areas: using a seat belt, getting exercise, eating right, getting enough sleep, or wearing safety helmets?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

The following "shots" (immunizations) are helpful to prevent bad diseases. Have you had them?

Yes

No

I am not sure

Yes

No

I am not sure

Violence or abuse

Sexual issues or birth control

AIDS and other sexually transmitted diseases

Depression and suicide

Substance abuse (beer, wine, drugs)

Exercise needs

Nutrition, eating disorders

A dentist

An eye doctor

A counselor or psychologist

Another doctor

Yes

No

Yes

No

less than 100 (45)
100-120 (46-55)
121-140 (56-64)
141-160 (65-73)
161-180 (74-82)
181-200 (83-91)
201-220 (92-100)
221-240 (101-109)
240 or more (>110)

What is your height in inches (within 2 inches)?

Feet: 3 4 5 6 7 Inches: 0 1 2 3 4 5 6 7 8 9 10 11

Less than 1 hour

1-3 hours

More than 3 hours

One single natural (or biological) parent

Two natural (or biological) parents

One natural (or biological) parent and one step parent

Living with another relative

Living with unrelated adult(s)

FAMILY

During the past month, how often did you talk about your problems, feelings, or opinions with someone in your family?

All of the time
Most of the time
Some of the time
A little of the time
None of the time

FEELINGS

During the past month, how often did you feel anxious, depressed, irritable, sad or downhearted and blue?

None of the time
A little of the time
Some of the time
Most of the time
All of the time

During the past month, if you needed someone to listen or to help you, was someone there for you?

Yes, as much as I wanted
Yes, quite a bit
Yes, some
Yes, a little
No, not at all

How would you rate the information your doctor or a nurse gave you about:

Yes

No

Not sure

Entering your zip code and other information is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.

ZIP:

Entering your zip code and other information is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.

ZIP:

If you wrote in an error or harm, please help us by choosing ANY of the following categories for this error.
(Please mark all that apply)

It caused harm, hurt or injury

It happenend within the last year

It happened to me

DOES THIS APPROACH MAKE A DIFFERENCE? YOU BET IT DOES!!

• in large research studies, 80% of doctors who used the "How's Your Health" approach gave better medical care compared to only 25% of the doctors who did not use the approach

• people like you who used the "How's Your Health" approach were made better off compared to those who received usual care

source: Effective Clinical Practice: 1999;2: 1-10

Entering your zip code is optional and will be used only to aggregate data for analysis. Remember that all information you provide on this survey is FOR YOUR EYES ONLY. While the information you provide is aggregated for statistical purposes, no individual information is stored.