Vital Care Final Questions Administered at Study Timepoints, Updated 12/23/20 

Vital Care Time Points 

Description Items Month O Month 1 Month 3 Month 6 

Vital Signs (n=4) Blood Pressure- Systolic 

Blood Pressure- Diastolic 

Pulse (Heart Rate) 

Body Weight 

X 

X 

X 

X 

x** X 

X 

X 

X 

X 

X 

X 

X 

- X 

X 

X 

- - -

Demographics 

(n=13) First Name 

Last Name 

Phone Number 

Secondary Phone 

Gender 

Date of Birth 

Language 

Primary Care Doctor 

Name or Address of Primary Care Doctor's Clinic 

If you use an Emergency Room, which one do you usually go to? 

Has any information changed on your demographic enrollment form? 

Emergency Contact(s) 

Emergency Contact(s) Phone 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

X 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

X 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

x* 

X 

x* 

x* 

- - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - - - - - - - - - - - - - - - - - - - - -

- - - - - - - - -- - - - -

Quetionnaires 

(n=S) Did you show your last blood pressure readings to your healthcare provider? 

Do you plan to show today's blood pressure readings to your healthcare provider? 

Did you take all your scheduled medications today? 

Have you fallen in the past 1-year?

Have you been hospitalized in the last 12 months 

Have you fallen since your last visit 

Have you been hospitalized since your last visit? 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

X 

- - - - - -- - X 

X 

X 

X 

- - - - - - - - - - - - - - - -

Legend: I 

*question is asked if they answer "Yes" to has any information changed in your demographic enrollment form?

**primary outcome measure I 
Summary of Validated ACL DASH Instruments 

Survey Link Comment 

BRFSS 

Questionnaire: 

htt12s://www.cdc.gov LbrfssLguestionnairesLindex.htm 8 questions were picked from the Demographics 

Section of this instrument and slightly modified to 

improve participants' understanding 

USDA Food 

Security Survey 

Module: 

htt12s://www.ers.usda.gov Lto12icsLfood-nutritionassistanceLfood-security-in-the-usLsurvey-toolsL#household Food lnsecurity_Hager et. al. 2013_Food Insecurity 

IHS_ 2 item screener- this publication discusses the 

validation of picking only 2 questions from this entire 

instrument 

Healthcare 

Utilization: NYC 

Department of 

Health and 

Mental 

Hygiene 

Community 

Health Survey 

htt12s ://wwwl. nyc.gov lsiteL dohL d ataL d ata-setsL communityhealth-survey-12ublic-use-data.12age 

Healthcare Utilization Survey- we picked 3 questions 

from two instruments. See Access section, pg. 17. 

Healthcare 

Utilization: 

National Health 

Interview 

Survey 

Reference: Gindi RM, Cohen RA, Kirzinger WK. Emergency 

room use among adults aged 18-64: Early release of 

estimates from the National Health Interview Survey, 

January-June 2011. National Center for Health Statistics. May 

2012. Available from: 

htt12:LLwww.cdc.gov LnchsLnhisLreleases.htm 

Healthcare Utilization Survey- we picked 3 questions 

from two instruments 

National Health 

Interview 

Survey: Blood 

Pressure 

Medicationshtt12s://www .cdc.gov LnchsL nh isl data-guestionnairesdocumentation.htm 

We picked 3 questions from this instrument. See 

Hypertension section. 

1 
Summary of Validated ACL DASH Instruments 

Adherence 

USCF 

htt1:2s://1:2revention.ucsf.eduLresourcesLsurvey-instrumentsand-scales The ACTG Adherence Baseline Questionnaire was 

modified from HIV to Hypertension 

NHANES 

Physical 

Activity 

htt1:2s://wwwn.cdc.govLnchsLnhanesLcontinuousnhanesLgues 

tionnaires.as1:2x?Begin Year=2017 

We picked 3 questions from the Physical Activity and 

Physical Fitness section 

Global Tobacco 

Surveillance 

System (GTSS) 

htt1:2s://www.cdc.gov LtobaccoLglobalLgtssLindex.htm We picked 3 questions from Section 3: Measuring 

Tobacco Smoking Prevalence of the GTSS. See page 6 

of the attachment. 

Alcohol Use 

Audit 

htt1:2s:LLauditscreen.orgL We picked 2 questions from this instrument 

htt1:2s:LLauditscreen.orgLcmsbLu1:2loadsLdrink less guestionn 

aire.1:2df 

Promis Social 

Isolation 

htt1:2s:LLwww.healthmeasures.netLindex.1:2h1:2?o1:2tion=com ins 

truments&view=measure&id=209 

Also available in Redcap shared library 

Patient Health 

Questionnaire 

(PHQ-2) 

htt1:2s:LLwww.hiv.uw.eduL1:2ageLmental-health-screeningL1:2hg2 

The PHQ-2 is the first two questions of the PHQ-9 

htt1:2s://www.1:2hgscreeners.comLselect-screener 

Charlson 

Comorbidity 

Survey 

htt1:2:LLwww.sbcdb.chLdownloadLHSM Su1:21:2I 8 charlson.1:2df This is the validated version. See link for the validated 

version from publication. We adapted the questions 

for self-administration in a community-based setting. 

See Methods in the Final Report. 

Food Behavior 

Checklist 

htt12s:LLsna12ed.fns.usda.govLlibraryLmaterialsLfood-behaviorchecklist 

2