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EXHIBIT C: PRE-INTERVENTION QUESTIONS (HEALTH AND WELLNESS) 

1. Coded Name of Patient #___________________

2. Interviewer: ____________________________ 

3. Date of Pre-Intervention Interview: ___mm/dd/yyyy___________ 

4. Read Informed Consent 

1☐ Yes 0☐ No

5. Agreed to Informed Consent 

1☐ Yes 0☐ No

6. Study Participant 

1☐ Yes 0☐ No

Thank you for agreeing to answer these questions. It is likely that you were asked these first 

three questions before, but we would like to ask them to you again. 

(Food Insecurity Trigger Questions) 

1. Are you worried that your food will run out before you have money to buy more? 

1☐ Yes 0☐ No 2☐ Declined to Answer 

2. In the last 2 months, have you run out of food that you bought, and didn't have money to get 

more? 

1☐ Yes 0☐ No 2☐ Declined to Answer 

3. I am not always physically able to: 

1. Shop 3☐ Cook 4☐ Feed Myself 5☐

2. 0☐ No difficulty with these ADL/IADLs 

3. 2☐ Declined to Answer 

4. Thinking about money for food, do you have enough money to pay for food each month? 

 1☐ Yes 0☐ No

5. Thinking about what money you have for food, what applies? 

1☐

☐

☐

☐

☐

 I ask family for food 

2 I ask friends for food 

3 I ask strangers for money for food 

4 I go to the food pantry for food 

5 Other, please specify: ______________________________________* 
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6. Have you eaten today or last evening in the last 12 hours? 

1☐ Yes 0☐ No 

6a. If No, how many hours is it since you last ate? ____# hours 

6b. If Yes or No? 

Where did you obtain food for you most recent meal? 

1 ☐

☐

☐

☐

☐

☐

☐

☐

 I bought it at a grocery 

 2 I bought it at a convenience store 

 3 I was given this food at a food pantry 

 4 My family provided me with food 

 5 A friend provided me with food 

 6 I attended a group congregate meal site 

 7 I receive home delivered meals 

 8 Other, Please specify_______________________________________________________* 

7. If food obtained in grocery or convenience or food pantry, did someone help you? 

1☐ Yes 0☐ No – I was able to get it myself 

7a. If yes, who helped you? ______________________________ 

8. Regarding the food that you do eat, which of the following statements is most true: 

1___

__

__

__

I can eat whatever I want, I am not on any special kind of diet 

2_ My doctor has told me that there are things that I should not eat and I am able to keep 

the diet that my doctor wants me to be on 

 3_ My doctor has told me that there are things that I should not eat, but I am unable to be 

keep the diet that my doctor wants me to be on. 

4_ I do not know what I should or should not eat 

9. As to shopping for food, which of the following statements is most true: 

1___

__

I am able to go to the store or food pantry and obtain my food 

2_ Sometimes, I can go to the store or food pantry and other times, I must rely on others 

 to shop for my food 

 3___ I am not able to go to the store or food pantry and obtain my food and must rely on 

 others to shop for my food 

10. As to cooking food, which of the following statements is most true: 

1___ I am able to cook food 

2___ Sometimes, I am able to cook food and other times, I must rely on others 

 to cook my food 

3___ I am not able to cook food and must rely on others to cook my food 
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11. I would like to ask you about where you live, please tell me which of the following describes where 

you live. 

1___I live in a home or apartment 

2___I live in an apartment in a senior building 

3___I live in a supportive or assisted living residence 

4___I live with friends 

5___ I stay with friends 

6___ I live with family 

7___ I do not have a permanent place to stay 

8___ I am homeless 

9___ Other, specify: ______________________* 

These next set of questions focus on your feelings about your health. 

(Questions taken from the PROMIS Global Health Tool) 

12. In general, would you say your health is: 

5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

13. In general, how would you rate your physical health? 

 5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

14. In general, how would you rate your mood and your ability to think?

 5___Excellent 4___Very Good 3____Good 2___Fair 1 ___Poor 

 (Question from the UCLA Loneliness Scale (R-UCLA) – Three Item Loneliness Scale) 

15. How often do you feel that you lack companionship? 

1___Hardly ever 2___Some of the Time 3___Often 

16. How often do you feel left out? 

1___Hardly ever 2___Some of the Time 3 ___Often 

17. How often do you feel isolated from others? 

1___Hardly ever 2 ___Some of the Time 3___Often 

(N-4-A Questions) 

18. On a weekly basis do you participate in social activities or attend organized groups, such as choirs, 

support groups, cultural performances, group meals, exercise classes? 

1___Yes 0___No 2____Declined to answer 

18a. If Yes, what activity (ies) do you participate? _________________________ 

19. Would you say that you often feel that a lack of companionship? 

0___Yes 1___No 2____Declined to answer 
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20. Is it difficult or impossible for you to leave your home without assistance? 

0___Yes 1___No 2____Declined to answer 

21. Do you see or talk to friends at least once a week? 

1___Yes 0___No 2____Declined to answer 

(Question from the Diener Satisfaction with Life Scale) 

For these next three (3) statements, think about a scale of one (1) to seven (7), with one (1) 

being that you strongly agree and seven (7) being that you strongly disagree with the 

statement. 

22. The conditions of my life are excellent 

What number would you give it? ____

23. I am satisfied with my life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree 

24. So far, I have gotten the important things I want in life 

What number would you give it? ____ 

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree

Now for my last question today . . . . 

25. Within the next six (6) weeks, how many appointments do you have scheduled with either your 

primary care physician, doctor or clinic or with a specialist or for physical or occupational therapy or 

counseling? Enter number of appointments: #______

Thank you very much. We will be calling you soon to find-out what programs and services you are receiving. 

We will also be calling you again in about eight (8) weeks to ask you some very similar questions as part of 

this study. Please do not hesitate to give us here at AgeOptions a call at 800-699-9043 if you have any 

questions. 

Interviewer: Indicate below where this participant was referred. This information will be part of the postintervention survey. 

26. Where was the participant referred for nutrition related services (check all that apply): 

1☐ Food Pantry 2☐ Congregate Dining Site 3☐ Home Delivered Meals 

4☐ Mather Lifeways Telephone Topics 5☐ AgeOptions Program 6☐ Government Programs

1_____Strongly Agree 2_____ Somewhat Strongly Agree 3_____Agree 4____Neither Agree or Disagree 

5_____Disagree 6______Somewhat Strongly Disagree 7____ Strongly Disagree