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* 1. Which of the following statement(s) best describe your current state of wellness?


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* 2. In the last 3 years, have you or a member of your family experienced a significant decline in ability to cope with daily life?

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* 3. In the last 3 years, have you or a member of your family experienced any of the following?

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* 4. In the last 3 years, which of the following has been your main source of healthcare services?

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* 5. How satisfied are you with the distance you have to travel to access your main source of healthcare services?

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* 6. Which of the following statements best describes how your primary care provider deals with your mental health concerns?  My primary care provider: 

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* 7. An NP can teach and support people to look after their health. Below is a list of common issues. Please indicate how you feel about your level of knowledge and capacity to deal with the following:

  I know enough I need more info I can deal with this  I need help N/A
Mood/ Anxiety/ Stress management
Headache / Migraine
Sleep
Chronic Pain 
Appetite / Weight
Lung Health / Smoking cessation
Mobility / Flexibility
Gut Health
Sexual Health
Diabetes 
Heart Health
Relationships
Addictions (drugs, alcohol, gaming etc.)
Coping as a Highly Sensitive Person
Trauma / PTSD
Grief
ADHD / other cognitive problems

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* 8. Health issue-specific groups which are facilitated by knowledgeable health professionals are often helpful to those with chronic illnesses. Such groups are often more affordable than individual interventions.

For which of the following health problems have you found a shortage of group treatment options in your community?

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* 9. Two resources which are important following a stay in hospital or a treatment centre are a good discharge plan and adequate support in preparing the home for the person who has not yet recovered their pre-exisiting level of independence.

If you or someone you know has had experience with this I would like your comments.

  strongly agree agree neither agree or disagree disagree Strongly disagree I have not had experience with this
My discharge plan provided sufficient instructions for self care and clear advice on how to deal with potential problems.
I had adequate support to set up my home and prepare ahead for the person returning home.
I would have liked to hire someone to help me with discharge planning and or setting up the home.

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* 10. Which of the following do you live closest to?

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* 11. How far would you drive to get to your healthcare provider?

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* 12. Check off the statements which best reflect your preferences.

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* 13. Many helpful health services are not covered by OHIP. For instance, psychotherapy, acupuncture, massage therapy and the services provided by NPs in private practice are not. Some people find it a worthwhile investment in their own and their family's wellness to budget for such services. Please indicate your ability to pay for some health services not covered by OHIP.

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* 14. Please indicate in which age group you fit.

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* 15. In what language would you prefer to receive your healthcare services?

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