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Database
Participant Information Survey
Participant ID as shown in Participant Survey
Workshop Location
Age Today
Sex
Male
Female
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
Race
American Indian or Alaska Native
Asian
Black, African-American
Native Hawaiian, Pacific Islander
White
Chronic Disease
Arthritis/Rheumatic Disease
Asthma/Emphysema/Other Chronic Breathing or Lung Problem
Cancer
Chronic Pain
Depression or Anxiety Disorder
Diabetes
Heart Disease
High Cholesterol
Hypertension
Kidney Disease
Osteoporosis
Obesity
Schizophrenia/Psychotic Disorder
Stroke
Other Chronic Condition
None (No Chronic Conditions)
Caregiver or Friend/Family
Yes
No
Deaf/Serious Difficulty Hearing
Yes
No
Blind/Serious Difficulty Seeing
Yes
No
Limited Due to Physical/Mental/Emotional
Yes
No
Lives Alone
Yes
No
Highest Grade of Schooling
Some elementary, middle, or high
High school graduate or GED
Some college or technical school
Bachelor's degree or higher
Health in General
Excellent
Very Good
Good
Fair
Poor
Dr/Care Provider Suggested Program
Yes
No
Confidence Managing Chronic Conditions
1
2
3
4
5
6
7
8
9
10
Session
1
2
3
4
5
6
Pre-Workshop Survey
Participant ID
Workshop Location
Hospitialized?
Yes
No
Times
ER Room?
Yes
No
Times
Dr. Visit?
(Required)
Yes
No
Times
Exercise
None
Less than 30 Minutes
30-60 Minutes
1-3 Hours
3+ Hours
Fallen?
Yes
No
Times
Missed Work
0 days
1-5 days
6-10 days
11+ days
N/A
Tobacco
Yes
No
Fatigue
1
2
3
4
5
6
7
8
9
10
Physical Pain
1
2
3
4
5
6
7
8
9
10
Emotional Distress
1
2
3
4
5
6
7
8
9
10
Interference
1
2
3
4
5
6
7
8
9
10
Managing
1
2
3
4
5
6
7
8
9
10
Medication
1
2
3
4
5
6
7
8
9
10
Do you have Medicare?
Yes
No
Do you have Medicaid?
Yes
No
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