SMI Clients -Client Exam and Survey-Baseline

Form Approved

OMB No. 0990-0371

Exp. Date XX/XX/20XX

ATTACHMENT 6

CLIENT PHYSICAL EXAM AND SURVEY

SECTION 1: PHYSICAL EXAM

Format

• Brief physical exam conducted by external contractor

Content

Primary

• Blood pressure: systolic and diastolic. Measured with digital sphygmomanometer

• BMI:

  • Weight (kg) – measured with standard medical scale

  • Height (cm) – measured with measuring stick built into standard medical scale

• HgbA1c or blood sugar: from blood sample – finger stick

• Total Cholesterol: from blood sample – finger stick

• HDL: from blood sample – finger stick

• LDL: from blood sample – finger stick

• Triglycerides: from blood sample – finger stick

Secondary

• Waist circumference

• Breath CO (ppm) for smoking status

PBHCI Program

Patient Survey

PAGE LEFT BLANK

INSTRUCTIONS

• You can use a pen or a pencil.

• All of your answers will be kept private and confidential.

• You can skip any questions that make you feel uncomfortable.

• Fill in the circle next to your answer or write your answer in the box provided.

MY OPINIONS

In order to provide the best possible mental health and related services, we need to know what you think about how well you were able to deal with your everyday life during the past 30 days.

Please tell us how much you disagree or agree with each of the following:

1. I deal effectively with daily problems. (shade one circle)

 Strongly disagree

 Disagree

 Agree

 Strongly agree

2. I am able to control my life. (shade one circle)

 Strongly disagree

 Disagree

 Agree

 Strongly agree

3. I am getting along with my family. (shade one circle)

 Strongly disagree

 Disagree

 Agree

 Strongly agree

4. My housing situation is OK with me. (shade one circle)

 Strongly disagree

 Disagree

 Agree

 Strongly agree

5. My symptoms are not bothering me. (shade one circle)

 Strongly disagree

 Disagree

 Agree

 Strongly agree

MY USE OF TOBACCO, ALCOHOL AND DRUGS

6. In the past 30 days, how often have you used tobacco products, such as cigarettes, chewing tobacco, cigars, etc. (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

7. How soon after waking do you smoke your first cigarette of the day? (shade one circle)

 I don’t smoke cigarettes

 5 minutes or less

 Between 6 and 30 minutes

 More than 60 minutes

8. How many cigarettes do you smoke per day? (shade one circle)

 I don’t smoke cigarettes

 More than 30

 Between 21 and 30

 Between 11 and 20

 Less than 10

9. In the past 30 days, how often have you used alcoholic beverages, such as beer, wine, liquor, etc.? (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

10. How many times in the past 30 days have you had four or more alcoholic drinks in a day? By “a drink” we mean a can of beer, glass of wine, or shot of liquor. (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

11. How many times in the past 30 days have you had five or more alcoholic drinks in a day? By “a drink” we mean a can of beer, glass of wine, or shot of liquor. (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

12. In the past 30 days, how often have you used an illegal drug, like marijuana, cocaine, heroin, etc., to get high? (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

13. In the past 30 days, how often have you used a prescription drug, like Xanax, Valium, Oxycodone, Percocet, etc., for some purpose other than to treat a medical or mental health condition? (shade one circle)

 Never

 Once or twice

 Weekly

 Daily or almost daily

14. In the past 30 days, how many times have you been arrested? (shade one circle)

 0 in the past 30 days

 1 time in the past 30 days

 2 times in the past 30 days

 3 times in the past 30 days

 More than 3 times, please write the number here: ________

MY EXPERIENCES

15. Staff here believe that I can grow, change and recover. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

16. Staff helped me obtain the information I needed so that I could take charge of managing my illness. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

17. I, not staff, decided my treatment goals. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

18. If I had other choices, I would still get services from this agency. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

19. I am happy with the friendships I have. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

20. I have people with whom I can do enjoyable things. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

21. I feel I belong in my community. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

22. In a crisis, I would have the support I need from family or friends. (shade one circle)

 Strongly disagree

 Disagree

 Undecided

 Agree

 Strongly agree

MY HEALTH

The next questions ask how often you have certain types of food available at home.

23. How often do you have fruits available at home? This includes fresh, dried, canned and frozen fruits. (shade one circle)

 Always

 Most of the time

 Sometimes

 Rarely

 Never

24. How often to you have any dark green vegetables (e.g., spinach, collard greens) at home? This includes fresh, dried, canned, and frozen. (shade one circle)

 Always

 Most of the time

 Sometimes

 Rarely

 Never

25. How often do you have 1% fat, skim or fat-free milk available at home? Please do not include 2% milk or soy milk. (shade one circle)

 Always

 Most of the time

 Sometimes

 Rarely

 Never

26. Add up all the time you spent in any kind of physical activity that increased your heart rate and made you breathe hard some of the time during the past 7 days.

During the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? (circle one number)

0 1 2 3 4 5 6 7

27. Over the past 30 days, on average how many hours per day did you sit and watch TV, videos or use the computer? (shade one circle)

 Less than one hour per day

 1 hour per day

 2 hours per day

 3 hours per day

 4 hours per day

 5 hours or more per day

28. How would you rate your overall health right now? (shade one circle)

 Excellent

 Very good

 Good

 Fair

 Poor

29. What kind of place do you usually go to when you are sick or need advice about your health? Is it a clinic, doctor’s office, emergency room, or some other place? (shade one circle)

 Clinic or health center

 Doctor’s office or HMO

 Hospital emergency room

 Hospital Outpatient Department

 Some other place

30. About how long has it been since you last saw or talked to a doctor or other health care professional about your health? Include doctors seen while you were a patient in a hospital. (shade one circle)

 6 months or less

 More than 6 months but not more than 1 year ago

 More than 1 year but not more than 3 years ago

 More than 3 years

 Never

31. Do you take prescription drugs on a regular basis? (shade one circle)

 Yes

 No

32. Do you take three or more prescription drugs on a regular basis? (shade one circle)

 Yes

 No

33. Do you currently have more than 5 prescription drugs in your medicine cabinet? (shade one circle)

 Yes

 No

3 4. Do you know how many of your prescription medications are for mental health problems?

 Yes write the number in the box:

 No

3 5. Do you know how many of your prescription medications are for physical health problems?

 Yes write the number in the box:

 No

36. Are you on any kind of diet, either to lose weight or for some other health-related reason? (shade one circle)

 Yes

 No

37. In the last 30 days, what services have you used? (check each box that applies)

 Medical care

 Employment services

 Family services

 Child care

 Transportation

 Education services

 Housing support

 Social recreational activities

 Consumer operated (peer) services

 HIV testing

ABOUT ME

38. What is your gender? (shade one circle)

 Male

 Female

 Transgender

 Something else

39. Are you Hispanic or Latino? (shade one circle)

 Yes

 No

40. What race do you consider yourself? (check each box that applies)

 Black or African American

 Asian

 Native Hawaiian or other Pacific Islander

 Alaska Native

 White

 American Indian

41. When were you born? (write the month, the date, and the year in the boxes)

42. What is the highest level of education you have finished, whether or not you received a degree? (shade one circle)

 Less than 12^th grade

 12^th grade/High school diploma/equivalent (GED)

 Voc/Tech diploma

 Some college or university

 Bachelor’s degree (BA, BS)

 Graduate work/Graduate degree

43. Are you currently enrolled in school or a job training program? (shade one circle)

 Not enrolled

 Enrolled full time

 Enrolled part time

 Something else

44. Are you currently employed? (check each box that applies)

 Employed full time (35+ hours per week, or would have been)

 Employed part time

 Unemployed – looking for work

 Unemployed – disabled

 Unemployed – volunteer work

 Unemployed – retired

 Unemployed – not looking for work

 Something else

45. In the past 30 days, where have you been living most of the time? (shade one circle)

 Owned or rented house

 Apartment, trailer, room

 Someone else’s house, apartment, trailer, room

 Homeless (shelter, street/outdoors, park), Group home

 Adult foster care

 Transitional living facility

 Hospital (medical)

 Hospital (psychiatric)

 Detox/inpatient or residential substance abuse treatment facility

 Correctional facility (jail/prison)

 Nursing home

 VA Hospital

 Veteran’s home

 Military base

 Somewhere else

THANK YOU FOR PARTICIPATING!

Please return your survey

to the staff member who gave it to you

***Staff Use Only***

Participant ID: __________ Site ID: ________________

Today’s Date: ___/___/___

Questionnaire was completed by:  Respondent  Interviewer

Survey Version 3-17-11

1

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