ࡱ>  )bjbjO O 0t-a-a 52!2!2!2!2!F!F!F!8~!T!F!=8"""""###7777777$W: =872!#####72!2!""7m$m$m$#v2!"2!"7m$#7m$m$35"`{)$"`47 80=8v4A?K$"A?,55A?2!5 ##m$#####77m$###=8####A?######### : Appendix A. Community Participation in Improving Health Status around Diabetes and Obesity Family Survey Instrument Welcome! We appreciate your participation in this important study, which is a partnership between the University of California Davis and the African American Leadership Coalition. The focus of this surveythe second phase of our studyis on learning more about your familys experiences with health, particularly around issues connected to diabetes and obesity. Please note that sometimes questions in the survey are for you personally, and sometimes we are asking you about health habits and attitudes of your family members. When you have completed this study, please mail it by June 15 to your study representative in the stamped envelope provided with this survey. Thank you very much for your time! Tina Roberts Dennis Styne, MD Roberts Family Development Center UC Davis Dept. of Pediatrics Co-Principle Investigator Principle Investigator Community Participation in Improving Health Status around Diabetes and Obesity Family Survey Instrument Demographic data: Ethnic origin _____Black, African/African American/Afro-Caribbean but non-Hispanic _____Hispanic _____White, non-Hispanic _____Filipino _____Asian or Pacific Islander _____American Indian/Alaskan Native _____Other______________________ Gender _____Male _____Female Please circle the highest year of school you have completed: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17+ Primary High School College Post-college What is the age range for each person in your family living with you? (Please check one age box for each family member) Do NOT write any names of family members on this table. PERSONAGE infant-56-1010-1415-1920--2930-3940-4950-5960-6970-7980+SelfSpouse/partnerChildChildChildChildMotherFatherOther family HEALTH STATUS In general, how would YOU rate your current health or well-being? (Circle one) 1 2 3 4 5 Excellent Very good Good Fair Poor Have you or anyone in your immediate family been diagnosed with diabetes and/or obesity? (Check all that apply) SELF ____Yes ____No IF YES: ___diabetes ___obesity Spouse/partner ____Yes ____No ___diabetes ___obesity Child/children ____Yes ____No ___diabetes ___obesity Your mother ____Yes ____No ___diabetes ___obesity Your father ____Yes ____No ___diabetes ___obesity Other close relative ____Yes ____No ___diabetes ___obesity Where do you typically get your information on diabetes or obesity? (Check all that apply) ____Doctors ____Internet ____Books or newsletters on health ____Family members or friends ____Television ____Faith-based organizations (e.g., church, temple, mosque, etc.) ____Schools ____Other (please list: ______________________________________________) Please rate your knowledge about diabetes on a scale of 1 5 (Circle one): 1 2 3 4 5 Very low Low Moderate High Very high 9 a. Please rate your knowledge about obesity on a scale of 1 5 (Circle one): 1 2 3 4 5 Very low Low Moderate High Very high 9 b. What would you like to know about diabetes or obesity that you do not already know? ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ What are barriers for you and family members to getting better care around diabetes and obesity? (Check all that apply) ____Lack of insurance ____Communication with doctors ____Lack of knowledge on resources around these diseases ____Lack of transportation to doctor/health facility ____Other (please list: ______________________________________________) 11. Do you consider yourself overweight or obese? ____Yes ____No 12. Has your doctor informed you that you are overweight or obese? ____Yes ____No 13 a. Is anyone in your immediate family overweight or obese? ____Yes ____No If yes, who? (Check all that apply) ____Mother ____Father ____Spouse ____Child/children ____Other (please list: _____________________________________________) 13 b. Do you think there are risks to being overweight or obese? (Check one) ____Yes ____No ____Not sure 13 c. If yes, what are some of the risks? _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________ 14 a. List three foods that you think should be in a healthy meal: _____________________________________________ _____________________________________________ _____________________________________________ 14 b. How often do you and your family eat healthy meals? (Circle one) 1 2 3 4 5 Never Rarely Sometimes Almost Always Always 14 c. Please check any of the following that make it challenging to eat healthy or healthier: (Check all that apply) ____Lack of knowledge about what foods are considered healthy ____Lack of nearby grocery stores or markets with healthy foods ____Lack of transportation to sources of healthy foods ____The high cost of healthy foods ____Lack of time needed to prepare healthy meals ____Other (please list: ______________________________________________ _____________________________________________________________) 15 a. How often do YOU exercise? (Circle one) 1 2 3 4 5 Never Rarely Sometimes Almost Always Always 15 b. What kinds of physical activity do YOU engage in? Please check the box that shows the amount of time you spend doing any of the following activities: ACTIVITYNo timeLess than 30 minutes per week30-60 minutes per week1-3 hours per weekMore than 3 hours per weekStretching, strengtheningWalkingSwimmingBicyclingAerobic exercise RunningOTHER (write in below) 16. Please check any of the following that make it difficult or challenging for you to exercise: (Check all that apply) ____No place to walk ____Unsafe environment for outside activity ____No access to equipment ____No time for exercise ____Not interested ____Health problems (please list:______________________________________) ____Other (please list:_______________________________________________ _____________________________________________________________) 17 a. Do you feel other members of YOUR FAMILY get enough exercise? (Check one) ____Yes ____No 17 b. Please check any of the following that make it difficult or challenging for YOUR FAMILY MEMBERS to exercise: (Check all that apply) ____No place to walk ____Unsafe environment for outside activity ____No access to equipment ____No time for exercise ____No physical education program in schools ____Not interested ____Health problems (please list:______________________________________) ____Other (please list:_______________________________________________ _____________________________________________________________) 18. Where do you and your family members receive medical care? (Check all that apply) ____family physician ____community clinic ____emergency room ____I do not receive medical care ____Other (please list:_______________________________________________) THANK YOU VERY MUCH!      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Community Participation in Improving Health Status around Diabetes and Obesity: Family Health InstrumentSurvey questionsSAfrican Americans, diabetes mellitus, obesity, health care disparities, focus group Linda Ziegahn#Immoor, Kristen (CDC/OD/OADC) (CTR),        Oh+'0d4L    , 8DLT\xAppendix A. Community Participation in Improving Health Status around Diabetes and Obesity: Family Health InstrumentSurvey questionsLinda ZiegahnTAfrican Americans, diabetes mellitus, obesity, health care disparities, focus group Normal.dotm$Immoor, Kristen (ob/OD/OADC) (CTR)3Microsoft Office Word@G@Z+~?@cM@o{՜.+,D՜.+, hp  e,Centers for Disease Control and Prevention;  uAppendix A. 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