Taryn
Here's a list of my questions. I wasn't sure of what kind of format we were going for (multiple choice, yes/no, open response)... so I just gave some generic multiple choice questions about physical activity/body image.
1. In general, how would you describe your overall health?
A. excellent
B. very good
C. good
D. fair
E. poor
2. How many days a week do you play sports, are physically active and/or exercise enough to make you sweat, heart beat fast, and/or breathe hard?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
3. When exercising, how long do your exercise sessions last?
A.0 minutes (they do not exercise)
B. 15 minutes
C. 30 minutes
D. 1 hour
E. More than one hour
4. How would you describe your weight?
A. Very underweight
B. Slightly underweight
C. About the right weight
D. Slightly overweight
E. Very overweight
5. Which of the following are you trying to do about your weight?
A. Lose weight
B. Gain weight
C. Stay the same weight
D. I am not trying to do anything about my weight
Christine
Within the past 30 days, how often did you or your partner(s) use a condom or another protective barrier during oral sex?
Within the past 30 days, how often did you or your partner(s) use a condom or another protective barrier during vaginal sex?
Within the past 30 days, how often did you or your partner(s) use a condom or another protective barrier during anal sex?
The last time you had vaginal sex did you or your partner use a condom or another protective barrier?
Would you be able to refuse sex if you or your partner did not have a condom or other protective barrier?
Wajiha
1. Over the past 30 days have you walked or bicycled as part of getting to and from work, or school, or to do errands?
- Yes-1
- No-2
- Unable to do activity-3
- Refused/Don’t know
2. Over the last month, how often did you walk or bicycle as part of getting to and from work, or school, or to do errands? How many times per day, per week, or per month did you these activities?
Code as 1_ for day, 2_ for week, and 3_ for month. Second digit would be the number of times respondent says.
3. Over the last month, did you do any vigorous activities for at least 10 minutes that caused heavy sweating, or large increases in breathing or heart rate? Some exercises are running, lap swimming, aerobic classes or fast bicycling?
- Yes-1
- No-2
- Unable to do activity-3
- Refused/Don’t know
4. Over the past 30 days, did you do moderate activities for at least 10 minutes that cause only light sweating or a slight to moderate increase in breathing or heart rate? Some examples are brisk walking, bicycling for pleasure, golf, and dancing.
- Yes-1
- No-2
- Unable to do activity-3
- Refused/don’t know
5. About how many hours did you sit and watch TV or videos yesterday? Would you say…
- Less than an hour-1
- 1 hour
- 2 hours
- 3 hours
- 4 hours
- 5 hours or more
- None
- Refused/don’t know
Alexis
1. “How often do you choose products rich in fiber?” (1 = almost never; 5 = almost every time).
2. "How often do you read the information on food labels?" (1 = almost never; 5 = almost every time).
3. What’s your first priority in choosing food?
Health
Cost
Flavor
4. About how many servings of fruit do you eat each day?
5. About how many servings of vegetables do you eat each day?
Serving sizes:fruit could be:
1 small apple
1 large banana
1 large orange
8 large strawberries
1 medium pear
2 large plums
32 seedless grapes
1 cup (8 oz.) of 100% juice
½ cup of dried fruit
1 small wedge of watermelon (1 inch thick)
3 broccoli spears, 5 in. long
1 cup of cooked leafy greens
2 cups of lettuce or raw greens
12 baby carrots
1 medium potato
1 large sweet potato
1 large ear of corn
1 large raw tomato
2 large celery stalks
1 cup of cooked beans
Melody
1. Do you currently have some kind of Health Insurance (This could be dichotomous or categorical depending on limits/purpose)?
2. Are you familiar with the Patient Protection and Affordable Care Act of 2010 also known as the Affordable Care Act, the Health Law, or President Obama’s Healthcare Plan.
3. If yes insured and yes familiar with health law: Do you believe that your health care costs will increase or decrease with the PPACA?
- If no insured and yes familiar with health law: Do you believe the health care you get from the PPACA will be the same as private insurance?
- If no PPACA skip to question 4.
4. Have you received any of the following in the past 12months/1 year (check all that apply):
- Routine Doctor’s Appointment
- Wellness/Preventive Screening (Pap, Prostate, CRC Screen, Mammo)
- Dental Exam (Routine/Preventive bitewings/cleaning)
- Vaccine/Flu Shot
- Birth Control or Safe Sex
5. If a-e<5: Would you be more or less likely to participate in items a-e if there were no copay/co-insurance (yes, no, no difference, idk)
- If a-e=5: What other preventive behaviors do you practice? (open ended/behavior perception ie helmet laws)
Sinyoung
Road Safety
1. When you rode a bicycle during the past 12 months, how often did you wear a helmet?
A. I did not ride a bicycle during the past 12 months
B. Never wore a helmet
C. Rarely wore a helmet
D. Sometimes wore a helmet
E. Most of the time wore a helmet
F. Always wore a helmet
2. How often do you wear a seat belt when driving a vehicle?
A. Never
B. Rarely
C. Sometimes
D. Most of the time
E. Always
Physical Exercise
3. During the past 7 days, on how many days did you exercise for a total of at least 60 minutes per day?
A. 0 days
B. 1 day
C. 2 days
D. 3 days
E. 4 days
F. 5 days
G. 6 days
H. 7 days
Hand washing
4. Do you wash your hands every time after using the rest room?
A. Yes
B. No
5. Do you wash your hands every time before eating?
A. Yes
B. No
Beth
1. Do you believe childhood vaccine are:
- Safe
- Unsafe
- Neither safe nor unsafe
2. Have you considered opting out of vaccines for your child?
- Yes
- No
3. Do you take any measures to avoid mosquito bites?
- Yes
- No
4. If yes, what measures do you take (check all that apply)
- Mosquito repellent/bug spray (ex: DEET, Off)
- Wear long sleeves and/or pants
- Stay inside when mosquitoes are biting
- Dumping standing water around the house
- Other (specify)
5. How often do you wear mosquito repellent when you go outside?
- Always
- Sometimes
- Rarely
- Never
Brad
1. Are you limited in any way in any activities because of physical, mental, or emotional problems?
2. Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?
3. Because of any impairment or health problem, do you need the help of other persons in handling your routine needs, such as everyday household chores, doing necessary business, shopping, or getting around for other purposes?
4. Because of any impairment or health problem, do you need the help of other persons with your personal care needs, such as eating, bathing, dressing, or getting around the house?
5. What is your main health condition or disability that limits your activity?
John
1. Have you ever received vaccination for human influenza (‘flu vaccine’)?
· Yes
· No
· Unknown
[If Yes] Year of last vaccine?
2. In the last 12 months have you developed a respiratory illness (fever and cough or sore throat)?
· Yes
· No
[If Yes] Estimated # of episodes in last 12 months:
· 1-2;
· 3-5;
· >5
3. In the last 12 months have you missed work (or school) because of a respiratory illness?
· Yes
· No
[If Yes] Estimated # of days
4. How many times have you been bitten by a mosquito in the last week?
· Never
· 1-2
· 3-5
· >5
5. When you are outdoors, how often do you apply an insect repellant that contains DEET?
· Never
· Occasionally
· Usually
· Always
Maryam
1. Do you use sunscreen:
-multiple times a day
-daily
-few times a week
-few times a month
-few times a year
-never
2. Do you use tanning salons/products:
-weekly
-monthly
-at least once a year, but not every month
-less often
-never
3. Do you have children in the household
-yes
-no
4. Do your children use sunscreen?
-multiple times a day
-daily
-few times a week
-few times a month
-few times a year
-never
5. Do you have a primary care physician or a family doctor?
-yes
-no