Well-Being Assessment

The Patient Well-Being Assessment is a 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, barriers, symptoms and well-being status.

Physical Activity
1. In the past 7 days, how many days did you exercise? ___ days

Tobacco Use
4. In the last 30 days, have you used tobacco? □ yes □ no

Alcohol Use
7. In the past 7 days, how many days did you drink alcohol? ____ days

Nutrition
10. In the past 7 days, how many servings of fruit and vegetables do you eat per day?
(1 serving = 1 cup fresh vegetables, ½ cup cooked vegetables, or 1 medium piece of fruit. 1 cup = size of a baseball)
___ servings per day

11. In the past 7 days, how many servings of high fiber or whole grains food do you eat per day?
(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)
___ servings per day

12. In the past 7 days, how many servings of fried or high-fat foods did you typically eat each day?
(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.)
___ servings per day

13. In the past 7 days, how many sugar-sweetened (not diet) beverages did you consume each day?
___ sugar sweetened beverages consumed per day

Depression
15. In the past 2 weeks, how often have you felt down, depressed, or hopeless?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

16. In the past 2 weeks, how often have you felt little interest or pleasure in doing things?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

Anxiety
18. In the past 2 weeks, how often have you felt nervous, anxious, or on edge?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

19. In the past 2 weeks, how often were you not able to stop worrying or control your worrying?
□ Almost all of the time
□ Most of the time
□ Some of the time
□ Almost never

High Stress
20. How often is stress a problem for you in handling such things as:
- Your health?
- Your finances?
- Your family or social relationships?
- Your work?
□ Never or rarely
□ Sometimes
□ Often
□ Always

Social/Emotional Support
21. How often do you get the social and emotional support you need:
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Pain
22. In the past 7 days, how much pain have you felt?
□ None
□ Some
□ A lot

General Health
23. In general, would you say your health is
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor

24. How would you describe the condition of your mouth and teeth - including false teeth or dentures?
□ Excellent
□ Very Good
□ Good
□ Fair
□ Poor

Activities of Daily Living
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? □ yes □ no

Instrumental Activities of Daily Living
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? □ yes □ no

Sleep
27. Each night, how many hours of sleep do you usually get?
___ hours

29. In the past 7 days, how often have you felt sleepy during the daytime?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Blood Pressure - Self Reported
30. If your blood pressure was checked within the past year, what was it when it was last checked?
□ Low or normal (at or below 120/80)
□ Borderline high (120/80 to 139/89)
□ High (140/90 or higher)
□ Don't know/not sure

Cholesterol - Self Reported
31. If your cholesterol was checked within the past year, what was it when it was last checked?
□ Desirable (below 200)
□ Borderline high (200-239)
□ High (240 or higher)
□ Don't know/not sure

Blood Glucose - Self Reported
32. If your glucose was checked, what was your fasting blood glucose (blood sugar) level the last time it was checked?
□ Desirable (below 100)
□ Borderline high (100-125)
□ High (126 or higher)
□ Don't know/not sure

Fall Risk
40. How many time have you fallen in the past 12 months?
___ total number of times

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

Patient Activation
42. I fully understand my chronic conditions (i.e, asthma, high blood pressure), their potential risks and how they can be managed?
□ Agree
□ Somewhat Agree
□ Disagree

43. I am confident I can self-manage my chronic conditions to prevent them from worsening or impacting my well-being?
□ Agree
□ Somewhat Agree
□ Disagree

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

Goals
45. My health conditions don't prevent me from pursuing my passions or what provides me purpose and meaning in my life?
□ Agree
□ Somewhat Agree
□ Disagree

Responsibilities
45. 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?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Access & Logistics
47. I have missed medical treatments (including medications) because I lacked transportation or it wasn't convenient enough?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Social
48. I feel isolated from others?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Support
49. In the past year, my family has provided physical and emotional support when I needed it
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

50. In the past year, I suffered through health conditions, medical concerns, or skipped medical treatments because I didn't have someone to help me?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Community
51. I feel safe walking on my street and through my neighborhood?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Home
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)?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never

Financial
53. In the past year, I've experienced interruptions in nutritional food, medicine, or treatment due to financial constraints?
□ Always
□ Usually
□ Sometimes
□ Rarely
□ Never