Form MMH-2 "Chronic Disease Self-management Program "take Control of Your Health" Post-workshop Participant Survey" - New Jersey

What Is Form MMH-2?

This is a legal form that was released by the New Jersey Department of Health - a government authority operating within New Jersey. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the New Jersey Department of Health;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a printable version of Form MMH-2 by clicking the link below or browse more documents and templates provided by the New Jersey Department of Health.

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Download Form MMH-2 "Chronic Disease Self-management Program "take Control of Your Health" Post-workshop Participant Survey" - New Jersey

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New Jersey Department of Health
Office of Minority and Multicultural Health
CHRONIC DISEASE SELF-MANAGEMENT PROGRAM
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
ID Number:
Date:
Zip Code:
I. In general, would you say your health is: (check one)
Excellent
Very Good
Good
Fair
Poor
(Circle one)
II. Daily Activities
Almost
Not at all
Slightly
Moderately
Quite a bit
totally
During the past 2 weeks, how much has
1
your sickness stopped you from being with
0
1
2
3
4
family, friends, neighbors or groups?
During the past 2 weeks, how much has
your sickness stopped you from doing things
2
0
1
2
3
4
you enjoy like reading, playing sports or other
fun things?
During the past 2 weeks, how much has
your sickness stopped you from doing
3
0
1
2
3
4
everyday work around your house (e.g.
cleaning, cooking etc.)?
During the past 2 weeks, how much has
4
your sickness stopped you from doing other
0
1
2
3
4
things that you need to do such as shopping?
MMH-2
SEP 15
Page 1
New Jersey Department of Health
Office of Minority and Multicultural Health
CHRONIC DISEASE SELF-MANAGEMENT PROGRAM
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
ID Number:
Date:
Zip Code:
I. In general, would you say your health is: (check one)
Excellent
Very Good
Good
Fair
Poor
(Circle one)
II. Daily Activities
Almost
Not at all
Slightly
Moderately
Quite a bit
totally
During the past 2 weeks, how much has
1
your sickness stopped you from being with
0
1
2
3
4
family, friends, neighbors or groups?
During the past 2 weeks, how much has
your sickness stopped you from doing things
2
0
1
2
3
4
you enjoy like reading, playing sports or other
fun things?
During the past 2 weeks, how much has
your sickness stopped you from doing
3
0
1
2
3
4
everyday work around your house (e.g.
cleaning, cooking etc.)?
During the past 2 weeks, how much has
4
your sickness stopped you from doing other
0
1
2
3
4
things that you need to do such as shopping?
MMH-2
SEP 15
Page 1
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
(Continued)
III. Controlling My Sickness
For each of the following questions, please
Strongly
Strongly
Disagree
Neutral
Agree
circle one number for each question that tells
disagree
agree
how you feel about doing things easily at this
time:
Feeling tired from being sick does not stop me
1
2
3
4
5
1
from doing things that I want to do.
Feeling pain, aches, or hurting from being sick
2
does not stop me from doing things I want to
1
2
3
4
5
do.
Feeling upset, sad, or crying from being sick
1
2
3
4
5
3
does not stop me from doing things I want to
do.
Feeling any other signs of sickness or health
4
problems (aches, pains, or being sad) does
1
2
3
4
5
not stop me from doing things I want to do.
I can do things I need to do to control my
5
sickness so that I don’t go to the ER or ask to
1
2
3
4
5
see my doctor.
I can do things other than just take a pill to
1
2
3
4
5
6
stop my sickness from being a problem every
day.
IV. During the past week I was able to stretch, walk, swim, bike, or do other types of exercise for:
(check only one)
None
Less than 30 minutes/week
30 - 60 minutes/week
1 – 3 hours/week
More than 3 hours/week
V. As a result of this workshop, I have made changes to my lifestyle, i.e., healthy eating, exercise, etc.?
(check only one)
Strongly agree
Agree
Disagree
Strongly disagree
MMH-2
SEP 15
Page 2
“TAKE CONTROL OF YOUR HEALTH”
POST-WORKSHOP PARTICIPANT SURVEY
(Continued)
(Circle one)
VI. Medical Care
When you go to your doctor:
Almost
Some-
Fairly
Very
(please circle one number for each
Never
Always
never
times
often
often
question)
Do you make a list of questions for your
0
1
2
3
4
5
1
doctor?
Do you ask questions about the things you
2
want to know and things you don’t
0
1
2
3
4
5
understand?
Do you talk about things other than your
0
1
2
3
4
5
3
being sick?
In the past 2 months, how many TIMES did you visit a doctor?
4
________ times
(Do not include hospital or ER visits)
In the past 2 months, how many TIMES did you go to a walk-in-clinic for
5
________ times
an emergency?
In the past 2 months, how many TIMES did you go to a hospital
6
________ times
emergency room?
In the past 2 months, how many TIMES were you admitted to the hospital
7
________ times
for one night or longer?
VII. Check all that apply:
I am a member with a sickness.
Yes
No
I take care of someone with a sickness.
Yes
No
VIII. This survey was completed: (check only one)
Without help
With some help
Thank you for completing the survey!
MMH-2
SEP 15
Page 3
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