Bright Futures for Women's Health and Wellness

Section I: About You and Your Health

OMB No. 0915-xxxx

Expiration Date:

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The OMB control number for this project is 0915-xxxx. Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-33, Rockville, Maryland, 20857.

1. How old were you on your last birthday?

years old

2. What grade are you in? (please check one)

 6th grade

 7th grade

 8th grade

 9th grade

 10th grade

 11th grade

 12th grade

 Other (please specify)

3. Are you Hispanic or Latina? (please check one)

 No, I am not Hispanic or Latina

 Yes, I am Hispanic or Latina

4. Which one or more of the following would you say is your race? (please check all that apply)

 White

 Black or African American

 American Indian or Alaska Native

 Asian

 Native Hawaiian or other Pacific Islander

5. How do you describe your health in general? (please check one)

 Excellent

 Very good

 Good

 Fair

 Poor

6. Do you consider yourself to be: (please check one)

 Very underweight

 Slightly underweight

 Healthy weight

 Slightly overweight

 Very overweight

Section II: Before You Saw Your Health Care Provider Today

7. Is this where you go most often for health care? (please check one)

 Yes

 No

8. Which sentence is the most true about your physical activity level? (please check one)

 I am thinking of making changes sometime in the future.

 I am thinking of making changes soon.

 I just started changing how much I do.

 I do a lot of physical activity every day.

 I haven’t thought about physical activity.

9. Which sentence is the most true about what you eat?
(please check one)

 I am thinking of making some changes sometime in the future.

 I am thinking of making some changes soon.

 I just changed the types/amount of food I eat.

 I make sure that I eat healthy foods in the right amount
every day.

 I haven’t thought about healthy eating.

10. BEFORE coming to see your health care provider today did you plan to talk to her/him about…? (please check one for each item)

Planned to talk about…?	Yes	No
a. Physical activity?
b. Healthy eating?

Section III: During Your Visit with Your Health Care Provider

11. Had you heard of or seen the “My Bright Future: Physical Activity and Healthy Eating Guide for Young Women” and wallet card before today?
(please check one)

 Yes

 No

 I don’t know

12. Which of these things happened during this visit? If it happened, how helpful do you think it will be to your health?
(please check yes or no in the first column, and if you check yes, check how helpful it was in the columns that follow)

	Did this happen?	If you checked yes, how helpful was it?
		Not at all helpful	Not helpful	Helpful	Very helpful
a. Before seeing my health care provider, I answered the physical activity questions.	 No Yes 				
b. Before seeing my health care provider, I answered the healthy eating questions.	 No Yes 				
c. I thought about questions to ask my health care provider about physical activity and/or healthy eating.	 No Yes 				
d. My health care provider and I talked about the foods I eat and how much of them I eat every day.	 No Yes 				
e. My health care provider and I talked about what sorts of physical activity I do regularly.	 No Yes 				
f. I was told my body mass index (BMI) percentile and what it means.	 No Yes 				
g. My health care provider suggested what I could do to eat healthier.	 No Yes 				
h. My health care provider suggested ways I could become more physically active.	 No Yes 				
i. I set goals with my health care provider about how to eat healthier.	 No Yes 				
j. I set goals with my health care provider about how to be more physically active regularly.	 No Yes 				

13. How certain are you that…? (please check one response for each statement)

	Not at all certain	Not very certain	Not sure how certain I am	Somewhat certain	Very certain
a. You can reach healthy eating goals if you set them with your health care provider?					
b. You can reach physical activity goals if you set them with your health care provider?					
c. People who are important to you will help you reach your healthy eating goals?					
d. People who are important to you will help you reach your physical activity goals?					
e. You have the information you need to reach your healthy eating goals?					
f. You have the information you need to reach your physical activity goals?					
g. You know what practical steps to take to reach your healthy eating goals?					
h. You know what practical steps to take to reach your physical activity goals?					
i. The wallet card will remind you of ways to be active and eat healthy?					

Section IV: After Your Visit with Your Health Care Provider

14. How much do you agree with these statements? (please check one response for each statement)

	Strongly Disagree	Disagree	Not sure if I agree or disagree	Agree	Strongly Agree
a. Healthy eating is something that I should talk about with my health care provider.					
b. Physical activity is something I should talk about with my health care provider.					
c. I did not learn anything new about healthy eating at my visit today.					
d. I did not learn anything new about physical activity at my visit today.					
e. It is important to me to reach my healthy eating goals.					
f. It is important to me to reach my physical activity goals.					
g. Talking to my health care provider helped me think about changing what I eat.					
h. Talking to my health care provider helped me think about being more active.					
i. Because of my visit today, I will try to eat more healthy foods.					
j. Because of my visit today, I will try to change how much or the type of physical activity I get.					

15. How much do you agree with these statements? (please check one answer for each statement)

	Strongly disagree	Disagree	Not sure if I agree or disagree	Agree	Strongly agree
a. In the future I will talk to my health care provider about healthy eating. I will start the conversation if he/she doesn’t ask me first.					
b. In the future I will talk to my health care provider about physical activity. I will start the conversation if he/she doesn’t ask me first.					

16. Please indicate if you plan to make changes in your physical activity level and in what you eat. If you don't plan on making any changes choose an option that indicates why (please check one response for each behavior).

	I plan to make changes	I am already doing all I need to	Other things are more important to me	I don’t know how to start	Other
a My Physical Activity					
b. What I Eat					

17. Do you have any other comments about the “My Bright Future: Physical Activity and Healthy Eating Guide for Young Women” and wallet card? (PLEASE PRINT)

THANK YOU FOR HELPING US OUT!
BEFORE YOU LEAVE, PLEASE PUT THIS FORM IN THE ENVELOPE PROVIDED AND GIVE IT TO THE PERSON AT THE FRONT DESK.

Bright Futures for Women’s Health and Wellness | Healthy eating and Physical Activity Materials | Adolescent Questionnaire 3