Program Name

 Participant Information Survey

Admin Use Only: Participant I.D.: The facilitator or program staff should complete this part of the form and 

mark the sequential number of the participant to the name on the attendance form. 

State abbreviation: __ __ (e.g., NY, VA, etc.) 

First four letters of the site name: __ __ __ __ 

Start date of program: __ __ / __ __ / __ __ (e.g., 12/01/19) 

Participant number: __ __ (e.g., 01, 02, 03, etc.) 

1. Did your doctor or other health care provider suggest that you attend this program?

 O Yes O No

2. How old are you today? ______ years

3. Are you: O Male or O Female?

4. Are you of Hispanic, Latino, or Spanish origin? O Yes O No

5. What is your race? Mark all that apply.

O American Indian or Alaska Native

O Asian

O Black or African American

O Native Hawaiian or other Pacific Islander

O White

6. Are you deaf or do you have serious difficulty hearing? O Yes O No

7. Are you blind or do you have serious difficulty seeing, even when wearing glasses? 

 O Yes O No

8. Do you live alone? O Yes O No

9. What is the highest grade or year of school you completed?

 O Some elementary, middle, or high school

 O High school graduate or GED

 O Some college or technical school 

 O College 4 years or more

10. Have you ever served in the military? O Yes O No 

11. During the past year, did you provide regular care or assistance to a friend or family 

member who has a long-term health problem or disability? O Yes O No
12. In general, would you say that your health is:

 O Excellent O Very good O Good O Fair O Poor

13. Has a health care provider ever told you that you have any of the following chronic conditions?

14. Because of a physical, mental, or emotional condition, do you:

o Have serious difficulty concentrating, remembering, or making decisions?

O Yes O No

o Have difficulty doing errands alone such as visiting a doctor’s office or shopping? 

O Yes O No

15. Do you have serious difficulty walking or climbing stairs? O Yes O No

16. Do you have difficulty dressing or bathing? O Yes O No

17. How often do you feel lonely or isolated from those around you?

 O Always O Often O Sometimes O Rarely O Never

18.How sure are you that you can manage your condition so you can do the things you need and want to 

do?

Totally unsure 1 2 3 4 5 6 7 8 9 10 Totally sure

YES NO YES NO

Anxiety Disorder Chronic Pain

High Cholesterol Kidney Disease

Asthma/Emphysema/Other 

Chronic Breathing or Lung 

Problem

Osteoporosis (Low Bone Density)

Cancer or Cancer Survivor Obesity

Hypertension (High Blood 

Pressure)

Schizophrenia or Other Psychotic 

Disorder

Depression Stroke

Diabetes (High Blood Sugar) Arthritis/Rheumatic Disease 

Heart Disease Other Chronic Condition
TO BE COMPLETED AT LAST PROGRAM SESSION

Admin Use Only:

Participant I.D.: The facilitator or program staff should complete this part of the form and 

mark the sequential number of the participant to the name on the attendance form. 

State abbreviation: __ __ (e.g., NY, VA, MA, etc.)

First four letters of the site name: __ __ __ __ 

Start date of program: __ __ / __ __ / __ __ (e.g., 12 01 19) 

Participant number: __ __ (e.g., 01, 02, 03, etc.) 

1. In general, would you say that your health is:

 O Excellent O Very good O Good O Fair O Poor

2. How sure are you that you can manage your condition so you can do the things you need and want to 

 do?

Totally unsure 1 2 3 4 5 6 7 8 9 10 Totally sure

3. How often do you feel lonely or isolated from those around you?

 O Always O Often O Sometimes O Rarely O Never