Health Habits and Concerns Survey

Health Habits and Concerns

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1. In what year were you born?

In what year were you born?

2. Male or Female?

Male or Female? Male

Female

3. How many days per week (on average) do you participate in any kind of vigorous activity?

How many days per week (on average) do you participate in any kind of vigorous activity? Never

Seldom

1 to 2 days per week

3 to 4 days per week

5 to 6 days per week

Daily

4. Does your physician consider you to be

Does your physician consider you to be Underweight

At a healthy weight

Overweight

5. Please indicate which of the following medical conditions you currently have:

Please indicate which of the following medical conditions you currently have: High Blood Pressure Digestive Difficulties Heart Disease Cancer Liver Problems Diabetes Depression Anxiety Insomnia	Thyroid Problems Arthritis Problems with Mobility Cognitive Difficulties Memory Loss Loss of Balance Visual Impairment Hearing Loss
Accidental Injury (Please describe briefly) or Other Condition (please specify)

6. During the past year,...

7. How often (on average) do you smoke cigarettes, cigars, or pipes, or chew tobacco?

How often (on average) do you smoke cigarettes, cigars, or pipes, or chew tobacco? Never

Seldom – less than once per month

Once or twice each month

Once or twice each week

3 to 5 days per week

6 to 7 days per week

If daily, how many times (or how many cigarettes) per day?

8. How often (on average) do you have a drink containing alcohol?

How often (on average) do you have a drink containing alcohol? Never (Skip to Question 11)

Seldom – less than once per month

Once or twice each month

Once or twice each week

3 to 5 days per week

6 to 7 days per week

9. When you do drink alcohol, how many drinks do you have on a typical day? One drink is defined as one 12-oz beer, one 4-oz glass of wine, or one 1-oz shot of liquor.

When you do drink alcohol, how many drinks do you have on a typical day? One drink is defined as one 12-oz beer, one 4-oz glass of wine, or one 1-oz shot of liquor. 1 or 2

3 or 4

5 or 6

7 or 8

9 or more

10. If Female - How often during the past year have you had four or more alcoholic drinks on one occasion?
If Male - How often during the past year have you had five or more alcoholic drinks on one occasion?

If Female - How often during the past year have you had four or more alcoholic drinks on one occasion? If Male - How often during the past year have you had five or more alcoholic drinks on one occasion? Never

Monthly or less

2 to 4 times per month

2 to 3 times per week

4 to 6 times per week

Daily

11. During the past year,...

12. Which prescribed medications do you take on a regular basis, in what amounts, and how often?

Which prescribed medications do you take on a regular basis, in what amounts, and how often?

13. Which medications, herbs, other supplements or remedies not prescribed by a physician do you take on a regular basis, in what amounts, and how often?

Which medications, herbs, other supplements or remedies *not* prescribed by a physician do you take on a regular basis, in what amounts, and how often?

14. During the past year, how often have you consumed the following substances?

	Never	Less than Monthly	Monthly	Weekly	Daily
Cannabis (marijuana, pot, hash, etc.)	During the past year, how often have you consumed the following substances? Cannabis (marijuana, pot, hash, etc.) Never	Less than Monthly	Monthly	Weekly	Daily
Cocaine (coke, crack, etc.)	Cocaine (coke, crack, etc.) Never	Less than Monthly	Monthly	Weekly	Daily
Amphetamine type stimulants (speed, diet pills, ecstasy, etc.)	Amphetamine type stimulants (speed, diet pills, ecstasy, etc.) Never	Less than Monthly	Monthly	Weekly	Daily
Inhalants (nitrous, glue, petrol, etc.)	Inhalants (nitrous, glue, petrol, etc.) Never	Less than Monthly	Monthly	Weekly	Daily
Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc., other than as prescribed)	Sedatives or Sleeping Pills (Valium, Serepax, Rohypnol, etc., other than as prescribed) Never	Less than Monthly	Monthly	Weekly	Daily
Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.)	Hallucinogens (LSD, acid, mushrooms, PCP, Special K, etc.) Never	Less than Monthly	Monthly	Weekly	Daily
Opioids (heroin, morphine, methadone, codeine, etc., other than as prescribed)	Opioids (heroin, morphine, methadone, codeine, etc., other than as prescribed) Never	Less than Monthly	Monthly	Weekly	Daily
Other - specify:	Other - specify: Never	Less than Monthly	Monthly	Weekly	Daily

15. Do you ever use medications prescribed by your doctors differently than they are prescribed – for example, taking more or less than the amount prescribed, or taking the medication at different times?

Do you ever use medications prescribed by your doctors differently than they are prescribed – for example, taking more or less than the amount prescribed, or taking the medication at different times? No (skip to question 17)

Yes

16. If you answered Yes to question 15, for what reasons do you take medications other than as prescribed? Please check all that apply.

If you answered Yes to question 15, for what reasons do you take medications other than as prescribed? Please check all that apply. Using less than the amount prescribed to save money

Using less than the amount prescribed because of unwanted effects from the full dosage

Using more than the amount prescribed because more is needed to alleviate the symptom

Using more than the amount prescribed to help you sleep

Using more than the amount prescribed to help you relax

Using more than the amount prescribed to help you wake up or feel more alert

Other (please specify)

17. How do you pay for your doctor or hospital bills? Please check all that apply:

How do you pay for your doctor or hospital bills? Please check all that apply: Out of Pocket

Medicaid

Medicare Part A (Medicare insurance for hospital care)

Medicare Part B (Medicare insurance for physician visits and other non-hospital care)

Medicare/HMO (Insurance for people with Medicare who select to join a health maintenance organization)

Medigap Insurance (Additional insurance for people covered by Medicare)

Medicare Disability Insurance

Other public assistance Insurance

Military Veterans Insurance

Federal Employees Health Insurance

Private Traditional Insurance (Including HMO or PPO)

Name of Insurance Provider

18. In what types of outside assistance would you be most likely to participate? Please rate each of the following on the scale provided.

Thank You Very Much for Completing This Survey

	YES	NO
1. Are you basically satisfied with your life?	During the past year,... 1. Are you basically satisfied with your life? YES	NO
2. Have you dropped many of your activities and interests?	2. Have you dropped many of your activities and interests? YES	NO
3. Do you feel that your life is empty?	3. Do you feel that your life is empty? YES	NO
4. Do you often get bored?	4. Do you often get bored? YES	NO
5. Are you in good spirits most of the time?	5. Are you in good spirits most of the time? YES	NO
6. Are you afraid that something bad is going to happen to you?	6. Are you afraid that something bad is going to happen to you? YES	NO
7. Do you feel happy most of the time?	7. Do you feel happy most of the time? YES	NO
8. Do you often feel helpless?	8. Do you often feel helpless? YES	NO
9. Do you prefer to stay at home, rather than going out and doing new things?	9. Do you prefer to stay at home, rather than going out and doing new things? YES	NO
10. Do you feel you have more problems with memory than most?	10. Do you feel you have more problems with memory than most? YES	NO
11. Do you think it is wonderful to be alive now?	11. Do you think it is wonderful to be alive now? YES	NO
12. Do you feel pretty worthless the way you are now?	12. Do you feel pretty worthless the way you are now? YES	NO
13. Do you feel full of energy?	13. Do you feel full of energy? YES	NO
14. Do you feel that your situation is hopeless?	14. Do you feel that your situation is hopeless? YES	NO
15. Do you think that most people are better off than you are?	15. Do you think that most people are better off than you are? YES	NO

	YES	NO
1. After drinking alcohol, have you ever noticed an increase in your heart rate or beating in your chest?	During the past year,... 1. After drinking alcohol, have you ever noticed an increase in your heart rate or beating in your chest? YES	NO
2. When talking with others, do you ever underestimate how much alcohol you drink?	2. When talking with others, do you ever underestimate how much alcohol you drink? YES	NO
3. Does alcohol make you sleepy so that you often fall asleep in your chair?	3. Does alcohol make you sleepy so that you often fall asleep in your chair? YES	NO
4. After a few alcoholic drinks, have you sometimes not eaten or skipped a meal because you didn’t feel hungry?	4. After a few alcoholic drinks, have you sometimes not eaten or skipped a meal because you didn’t feel hungry? YES	NO
5. Does having a few alcoholic drinks help decrease your shakiness or tremors?	5. Does having a few alcoholic drinks help decrease your shakiness or tremors? YES	NO
6. Does alcohol sometimes make it hard for you to remember parts of the day or night?	6. Does alcohol sometimes make it hard for you to remember parts of the day or night? YES	NO
7. Do you have rules for yourself that you won't drink before a certain time of the day?	7. Do you have rules for yourself that you won't drink before a certain time of the day? YES	NO
8. Have you lost interest in hobbies or activities you used to enjoy?	8. Have you lost interest in hobbies or activities you used to enjoy? YES	NO
9. When you wake up in the morning, do you ever have trouble remembering part of the night before?	9. When you wake up in the morning, do you ever have trouble remembering part of the night before? YES	NO
10. Does having a drink help you sleep?	10. Does having a drink help you sleep? YES	NO
11. Do you hide your alcohol bottles from family members?	11. Do you hide your alcohol bottles from family members? YES	NO
12. After a social gathering, have you ever felt embarrassed because you drank too much?	12. After a social gathering, have you ever felt embarrassed because you drank too much? YES	NO
13. Have you ever been concerned that drinking might be harmful to your health?	13. Have you ever been concerned that drinking might be harmful to your health? YES	NO
14. Do you like to end an evening with a nightcap?	14. Do you like to end an evening with a nightcap? YES	NO
15. Did you find your drinking increased after someone close to you died?	15. Did you find your drinking increased after someone close to you died? YES	NO
16. In general, would you prefer to have a few drinks at home rather than go out to social events?	16. In general, would you prefer to have a few drinks at home rather than go out to social events? YES	NO
17. Are you drinking more now than in the past?	17. Are you drinking more now than in the past? YES	NO
18. Do you usually take a drink of alcohol to relax or calm your nerves?	18. Do you usually take a drink of alcohol to relax or calm your nerves? YES	NO
19. Do you drink alcohol to take your mind off your problems?	19. Do you drink alcohol to take your mind off your problems? YES	NO
20. Have you ever increased your drinking of alcohol after experiencing a loss in your life?	20. Have you ever increased your drinking of alcohol after experiencing a loss in your life? YES	NO
21. Do you sometimes drive when you have had too much to drink?	21. Do you sometimes drive when you have had too much to drink? YES	NO
22. Has a doctor or nurse ever said they were worried or concerned about your drinking alcohol?	22. Has a doctor or nurse ever said they were worried or concerned about your drinking alcohol? YES	NO
23. Have you ever made rules to manage your drinking of alcohol?	23. Have you ever made rules to manage your drinking of alcohol? YES	NO
24. When you feel lonely, does having an alcoholic drink help?	24. When you feel lonely, does having an alcoholic drink help? YES	NO
25. During the past year, have you ever felt you should cut down on drinking alcohol?	25. During the past year, have you ever felt you should cut down on drinking alcohol? YES	NO
26. Has anyone annoyed you by criticizing you for drinking alcohol?	26. Has anyone annoyed you by criticizing you for drinking alcohol? YES	NO
27. Has a friend or family member ever told you about things you said or did while drinking that you could not remember?	27. Has a friend or family member ever told you about things you said or did while drinking that you could not remember? YES	NO

	NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
1. Educational/Informational Presentations on Health or Quality of Life and Aging	In what types of outside assistance would you be most likely to participate? Please rate each of the following on the scale provided. 1. Educational/Informational Presentations on Health or Quality of Life and Aging NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
2. Educational/Informational Presentations on Medications and Substance Use in Older Adults	2. Educational/Informational Presentations on Medications and Substance Use in Older Adults NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
3. Outpatient Group Counseling (for Older Adults only) on Health or Quality of Life	3. Outpatient Group Counseling (for Older Adults only) on Health or Quality of Life NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
4. Outpatient Group Counseling (for Older Adults only) on Medications, Substance Use, Mental Health	4. Outpatient Group Counseling (for Older Adults only) on Medications, Substance Use, Mental Health NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
5. Outpatient Group Counseling (for all ages) on Health or Quality of Life	5. Outpatient Group Counseling (for all ages) on Health or Quality of Life NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
6. Outpatient Group Counseling (for all ages) on Medications, Substance Use, Mental Health	6. Outpatient Group Counseling (for all ages) on Medications, Substance Use, Mental Health NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
7. Faith-Based Group Counseling Conducted by a Minister or Other Religious Leader	7. Faith-Based Group Counseling Conducted by a Minister or Other Religious Leader NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
8. Individual Counseling on General Issues of Mental Health/Quality of Life	8. Individual Counseling on General Issues of Mental Health/Quality of Life NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
9. Individual Counseling Specifically Focused on Changing Behavior to Help Reduce the Use of Substances	9. Individual Counseling Specifically Focused on Changing Behavior to Help Reduce the Use of Substances NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
10. Faith-Based Individual Counseling Conducted by a Minister or Other Religious Leader	10. Faith-Based Individual Counseling Conducted by a Minister or Other Religious Leader NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
11. Marital/Family Therapy	11. Marital/Family Therapy NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
12. Self-Help Group Meetings like Alcoholics Anonymous or Narcotics Anonymous for Older Adults Only	12. Self-Help Group Meetings like Alcoholics Anonymous or Narcotics Anonymous for Older Adults Only NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
13. Self-Help Group Meetings like Alcoholics Anonymous or Narcotics Anonymous for All Ages	13. Self-Help Group Meetings like Alcoholics Anonymous or Narcotics Anonymous for All Ages NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
14. Residential Treatment for Older Adults Only to Help Reduce the Use of Substances	14. Residential Treatment for Older Adults Only to Help Reduce the Use of Substances NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
15. Residential Treatment for All Ages to Help Reduce the Use of Substances	15. Residential Treatment for All Ages to Help Reduce the Use of Substances NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
16. Private In-Home Counseling by a Psychotherapist	16. Private In-Home Counseling by a Psychotherapist NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate
17. Private In-Home Assistance by a Home Health Care Provider to Help Reduce the Use of Substances	17. Private In-Home Assistance by a Home Health Care Provider to Help Reduce the Use of Substances NOT Likely To Participate	SOMEWHAT Likely To Participate	FAIRLY Likely To Participate	HIGHLY Likely To Participate