Faith and Health Ministries Health Survey
2010
COMIRB # 10-0703
You were selected to participate in a health survey. The purpose of this survey is to gather information about
community health so that we can inform health institutions about the needs of the Black community. The survey is
voluntary and you do not have to answer any questions you do not want to. It takes about 10-15 minutes to complete.
Your answers will be confidential and not connected with your name. The Center for African American Health will
make a thorough report to the community about what was learned in the survey. There are no risks to taking this
survey. If you have any questions about the survey, please call Mr. Ralph Kennedy at the Center for African American
Health at 303-355-3423. PLEASE DO NOT WRITE YOUR NAME ON THIS SURVEY.
Please put an x in the appropriate box for each question in this survey or write your answer in the space provided.
HEALTH STATUS
Excellent
Very Good
Good
Fair
Poor
Don’t
know/not
sure
5
4
3
2
1
-1
1. In general, would you
say your health is:
HEALTH CONDITIONS
Yes
No
Don’t know/not
sure
a. You have diabetes?
1
0
-1
b. You have pre-diabetes or borderline diabetes?
1
0
-1
c. You had high blood pressure?
1
0
-1
d. You are pre-hypertensive or borderline high?
1
0
-1
e. That your blood cholesterol is high?
1
0
-1
f. You had a heart attack, also called a myocardial
infarction?
1
0
-1
g. You had angina or coronary heart disease?
1
0
-1
h. You had a stroke?
1
0
-1
i. You had an anxiety disorder?
1
0
-1
j. You have a depressive disorder?
1
0
-1
k. During the past year, have you received treatment,
such as counseling, therapy, or medication, from a
health professional, for feeling sad, blue or
depressed?
1
0
-1
2. Has a doctor, nurse or other heath professional
EVER told you that....
1
HEALTH BEHAVIORS
3. How often do you engage in moderate to vigorous exercise during an average week? (Vigorous exercise includes
activities like jogging, running, fast cycling, aerobics classes, swimming laps, singles tennis, and racquetball.
These types of activities make you sweat and make you feel out of breath. Moderate exercise includes activities
such as brisk walking, gardening, slow cycling, dancing, doubles tennis, or hard work around the house.)
0
Never
Rarely (1-2 times per week)
2 Sometimes (3-4 times per week)
3 Always or almost always (5 or more times per week)
1
4. How often do you eat at least five servings of fruits and vegetables per day?
0
Never
Rarely (1-2 times per week)
2 Sometimes (3-4 times per week)
3 Always or almost always (5 or more times per week)
1
5. On a typical day, how many glasses or cans of regular soda pop or other sweetened drinks, such as fruit punch or
sports drinks do you drink? Do NOT count diet drinks. (Includes any drinks with added sugar such as Cola, sunny
delight, iced tea, lemonade, Hawaiian punch, Hi-C, Snapple, Gatorade, Kool-Aid.)
___________ # of glasses or cans
6. In the past 7 days, how many times did you eat fast food? Include fast food meals eaten at school or at home, or
at fast food restaurants, carryout or drive thru.
________# of times in past 7 days
HEALTH KNOWLEDGE, ATTITUDES AND BELIEFS
Yes
No
Don’t know/not sure
a. Do you think pain or discomfort in the jaw, neck or
back are symptoms of a heart attack?
1
0
-1
b. Do you think pain or discomfort in the arms or
shoulder are symptoms of a heart attack?
1
0
-1
c. Do you think sudden trouble walking, dizziness, or
loss of balance are symptoms of a stroke?
1
0
-1
d. Do you think severe headache with no known cause is
a symptom of a stroke?
1
0
-1
7. Please select one of the three choices about your
knowledge of cardiovascular disease.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
a. My health largely depends on how well I take care of
myself.
4
3
2
1
b. I leave it to my doctor to make the right decisions
about my health.
4
3
2
1
8. Please indicate how strongly you agree or
disagree with each of the following statements.
2
FAMILY LIFESTYLES
This table is about the lifestyle of your family. Please rate how strongly you agree or disagree that each statement is
true of your family. By family, we mean family members who live in the same house, apartment, or dwelling.
9. Do you strongly disagree, disagree, agree,
strongly agree that these statements are true
about your family (that is, the family members
you live with)?
Strongly
Agree
Agree
Disagree
Strongly
Disagree
a. Family members encourage one another to eat
healthfully.
4
3
2
1
b. Family members expect each other to be physically
active.
4
3
2
1
d. Personal responsibility for health is encouraged by
my family.
4
3
2
1
g. Family members model health habits for each other.
4
3
2
1
HEALTH CARE PROVIDERS
10. Please indicate how strongly you agree or
disagree with each of the following
statements.
Strongly
Agree
Agree
Disagree
Strongly
Disagree
4
3
2
1
4
3
2
1
c. In most hospitals, African Americans and whites
receive the same kind of care.
4
3
2
1
d. African Americans can receive the healthcare they
want as equally as white people can.
4
3
2
1
a. Doctors treat African American and white patients
the same.
b. Racial discrimination in a doctor’s office is common.
HEALTH INSURANCE AND HEALTH SCREENINGS
11. Do you have any kind of health care coverage, including health insurance, prepaid plans
such as HMO's, or government plans such as Medicare?
1
Yes
0
No
-1
Don’t know/not sure
Yes
No
Don’t
know/n
ot sure
a. Cervical cancer with PAP test (Women only)
b. Prostate cancer (Men only)
c. Breast cancer
1
0
-1
1
0
-1
1
0
-1
d.
e.
f.
g.
1
0
-1
1
0
-1
1
0
-1
1
0
-1
12. Below are health conditions doctors sometimes screen for.
Has your doctor, nurse or other health provider screened you
in the past 2 years for any of the following?
Colon cancer
High cholesterol
High blood pressure
High blood glucose
DIABETES
3
13. Have you ever had a class in diabetes self-management?
1
0
Yes
No
14. Did you know that the Center for African American Health provides free diabetes self-management education?
1
0
Yes
No
15. Diabetes can be cured.
Strongly
Agree
Somewhat Agree
Unsure
Somewhat
Disagree
Strongly
Disagree
5
4
3
2
1
THE CENTER FOR AFRICAN AMERICAN HEALTH
16. How would you like to hear from the Center for African American Health about its offerings and activities in the
future? (Please check all that apply)
1
Mail
Radio
3 CAAH website
4 Telephone
5 Electronic news letter
6 Annual report
7 TV
8 E-mail
9 In-person contact
10 Text message
11 Online social networks (Facebook, Twitter, YouTube)
2
HEALTH CARE REFORM
A plan to make health care more affordable, holds insurers more accountable, expand coverage to all Americans and
makes our health system sustainable is moving forward. The following questions are about healthcare reform. Please
put an X in the box next to the response that best represents how you feel.
17. Healthcare reform is going to help me.
1
Yes
0
-1
No
Don’t know/not sure
18. Do you feel you understand what the impact of the healthcare reform law will be on you and your family?
1
Yes
0
-1
No
Don’t know/not sure
19. Given what you know about the new healthcare reform law, do you have a generally favorable or generally
unfavorable opinion of it?
1
Generally favorable
0
Generally unfavorable
-1
Don’t know/not sure
4
20. Please indicate how much
you agree or disagree
with the following
statements about the
health reform law.
Strongly Agree
Agree
Disagree
Strongly
Disagree
a. I feel disappointed
4
3
2
1
b. I feel confused
4
3
2
1
c. I feel pleased
4
3
2
1
d. I feel anxious
4
3
2
1
e. I feel relieved
4
3
2
1
f. I feel angry
4
3
2
1
g. I am not sure
4
3
2
1
ABOUT YOU
21. About how much do you weigh without shoes?
22. About how tall are you without shoes?
___________ lbs.
_________ ft __________inches
23. What is the zip code where you live? _________________________
24. Are you male or female?
1
Male
0
Female
25. Which one or more of the following best describes your race/ethnicity? Check all that apply.
1
African-American or Black (not of Hispanic origin)
American Indian or Alaska Native
3 Asian
4 Hispanic or Latino/a
5 Native Hawaiian or Other Pacific Islander
6 White (not of Hispanic origin)
7 Other: Please specify: ___________________________________
2
26. What is your age? __________
27. Are you currently…? 1 Employed full-time
5Other
2
Work part time
3
Unemployed
4Retired
__________________ (please specify)
28. What is the highest grade or year of school you completed?
0
Never attended school or only attended kindergarten
Grades 1 through 8 (Elementary)
2 Grades 9 through 11 (Some high school)
3 Grade 12 (High school graduate)
4 College 1 year to 3 years (some college or technical school)
1
5
5
College 4 years or more (college graduate)
29. What is your annual household income from all sources?
1
Less than $10,000
$10,000 to less than $15,000
3 $15,000to less than $20,000
4 $20,000 to less than $25,000
5 $25,000 to less than $35,000
6 $35,000 to less than $50,000
7 $50,000 to less than $75,000
8 $75,000 or more
2
THANK YOU FOR PARTICIPATING!
PLEASE ANSWER THE FOLLOWING QUESTIONS FROM
PASTOR__________
6