Participant Information SurveyParticipant ID as shown in Participant SurveyWorkshop LocationAge TodaySexMaleFemaleEthnicityNot Hispanic or LatinoHispanic or LatinoRace American Indian or Alaska Native Asian Black, African-American Native Hawaiian, Pacific Islander WhiteChronic 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/FamilyYesNoDeaf/Serious Difficulty HearingYesNoBlind/Serious Difficulty SeeingYesNoLimited Due to Physical/Mental/EmotionalYesNoLives AloneYesNoHighest Grade of SchoolingSome elementary, middle, or highHigh school graduate or GEDSome college or technical schoolBachelor's degree or higherHealth in GeneralExcellentVery GoodGoodFairPoorDr/Care Provider Suggested ProgramYesNoConfidence Managing Chronic Conditions12345678910Session 1 2 3 4 5 6 Pre-Workshop SurveyParticipant IDWorkshop LocationHospitialized?YesNoTimesER Room?YesNoTimesDr. Visit?*YesNoTimesExerciseNoneLess than 30 Minutes30-60 Minutes1-3 Hours3+ HoursFallen?YesNoTimesMissed Work0 days1-5 days6-10 days11+ daysN/ATobaccoYesNoFatigue12345678910Physical Pain12345678910Emotional Distress12345678910Interference12345678910Managing12345678910Medication12345678910Do you have Medicare?YesNoDo you have Medicaid?YesNo
