Can Do On Demand Survey

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* 1. Personal Information

First Name

Last Name

City/State

Zip

Birthdate

Gender

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* 2. Please specify your ethnicity:

White

Hispanic, Latino, or Spanish

Black or African American

Asian

American Indian or Alaska Native

Native Hawaiian or Other Pacific Islander

Other

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* 3. I am:

Person with MS

Spouse/Support Partner

Other Family Member

Friend

Healthcare Professional

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* 4. How did we do...

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience.	Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience. Strongly Agree	Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience. Agree	Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience. Neutral	Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience. Disagree	Overall, Can Do On Demand (content, delivery, ease of access and format) offers a high quality experience. Strongly Disagree

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* 5. Would you recommend Can Do On Demand to others?

Yes

Maybe

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* 6. Which module/s did you participate in (check all that apply)?

Dimensions of Wellness

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* 7. Because of participating in Can Do On Demand...

	Strongly Agree	Agree	Neutral	Disagree	Strongly Disagree
I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)?	I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)? Strongly Agree	I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)? Agree	I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)? Neutral	I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)? Disagree	I plan to make changes in my life (e.g., increase exercise or physical activity, better nutrition, better medication adherence, stop smoking, etc….)? Strongly Disagree
I am more aware of MS resources available to me.	I am more aware of MS resources available to me. Strongly Agree	I am more aware of MS resources available to me. Agree	I am more aware of MS resources available to me. Neutral	I am more aware of MS resources available to me. Disagree	I am more aware of MS resources available to me. Strongly Disagree
I learned new information, skills or strategies to improve my well-being and promote wellness in my life.	I learned new information, skills or strategies to improve my well-being and promote wellness in my life. Strongly Agree	I learned new information, skills or strategies to improve my well-being and promote wellness in my life. Agree	I learned new information, skills or strategies to improve my well-being and promote wellness in my life. Neutral	I learned new information, skills or strategies to improve my well-being and promote wellness in my life. Disagree	I learned new information, skills or strategies to improve my well-being and promote wellness in my life. Strongly Disagree

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* 8. Please check all the areas of wellness where you gained usable knowledge as a result of participating in Can Do On Demand:

Diet, Exercise, and Healthy Behaviors (Making positive lifestyle choices about regular physical activity geared to one’s abilities, healthy eating, weight control, MS care and primary care, and preventive health behaviors)

Emotional Well-being (Developing coping strategies to enhance problem solving, manage stress, foster a positive outlook, and develop resilience in the face of unpredictable changes)

Work and Home (Engaging in meaningful and rewarding activities that promote a sense of purpose and accomplishment)

Spirituality (Developing a world view that provides a sense of peace and harmony, and enables one to cope and adapt throughout life)

Relationships (Developing positive, healthy relationships that nurture interconnectedness with family, friends and community)

Cognitive Well-being (Engaging in mentally stimulating and challenging activities that lead to personal growth, enhanced creativity and new learning)

Other________

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* 9. What do you feel you gained from Can Do On Demand?

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* 10. Please share any suggestions you have to improve Can Do On Demand:

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* 11. Have you participated in any other Can Do MS Programs (if yes, please check all that apply)?

Webinar & Telelearning Series

JUMPSTART

TAKE CHARGE

CAN DO

This is my first Can Do MS experience

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* 12. Do you plan to participate in any other programs offered by Can Do MS?

Yes

Maybe