You are invited to participate in our survey "Veteran Weight Management Program Preference" questionnaire.
In this survey, approximately 200 people will be asked to complete a survey that asks questions about current health habits and preference in weight loss program delivery. The survey should take no more than 15 minutes to complete. Your participation may help to shape new weight management programming at your V.A. medical center.
Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.
Your survey responses will be stricly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.
In general, would you say that your health is: Please indicate (with a check mark to the left) any of the following that apply to you: Please indicate any of the following that apply to you: Have you tried to lose weight in the past? What of the following options have you tried in order to lose weight?
Check all that apply.
Are you trying to lose weight now? Select the answer that best describes your rate of weight gain over the years. Select the answer that best describes your family: How much can you rely on family or friends for support and encouragement? How important is controlling your weight to you personally?
Please mark the number that applies.
How confident are you that you can successfully change your eating and physical activity to control your weight?
Please mark the number that applies.
Mark the statement that most closely applies to you (choose one): How much weight do you think you realistically could lose in one year? Do any of the following have anything to do with your being overweight?
Check all that apply to you. What do you think may get in the way of changing your eating habits?
Check all that apply to you.
How many times a day do you typically eat, including snacks (choose one)? During a typical week, how many times do you eat at restaurants or buy ‘take out’ food?
Please choose a number between 0 and 21 from the drop down menu below. Consider breakfast, lunch and dinner 7 days a week for a total of 21 meals for which restaurant or take out food could be eaten. How much juice (including juice-drinks) or sugar-sweetened soda, tea, or other beverages do you drink most days? Do you drink alcoholic beverages (such as beer, malt liquor, wine, wine coolers, hard/distilled liquor)? How fast do you usually eat? On average, how often do you feel you have you eaten too much? What do you think may get in the way of changing your physical activity habits?
Check all that apply to you.
This next question asks about your physical activity habits. There are two types of activity to consider:
Moderate physical activities cause light sweating and a slight to moderate increase in breathing or heart rate. Examples include brisk walking, bicycling, vacuuming, gardening, and golfing without a cart.
Vigorous activities cause heavy sweating and large increases in breathing or heart rate. Examples include running, aerobic classes, heavy yard work, and briskly swimming laps.
How many days per week do you do moderate activities for at least 10 minutes at a time?
Please choose a number from 0 to 7.
On days when you do moderate activities for at least 10 minutes at a time, how much total time per day do you spend doing these activities? How many days per week do you do vigorous activities for at least 10 minutes at a time?
Please choose a number from 0 to 7.
If you were participating in a weight loss program, do you prefer group learning sessions to individual learning? Now we will ask a few questions related to your preference in a weight management program.
VA is now using telehealth. Telehealth is new technology that is changing health care. Telehealth involves the use of video, digital pictures, and messaging devices to treat you in locations that may be hundreds of miles from the medical center.
This new way of providing care uses both the computerized patient record and telehealth to link you with a care coordinator. You can use telehealth technologies to contact your care coordinator from home.
The V.A. provides all equipment needed in your home.
If you were to participate in a home-based weight management program using telehealth, how often would you prefer a face-to-face appointment with your doctor? The next 7 questions are demographic questions. Your responses are appreciated, but not required. You may any skip any question you do not want to answer. How far do you travel to the VA that provides your weight loss program? How often do you have someone help you read hospital materials? How confident are you in filling out medical forms by yourself? How often do you have problems learning about your medical condition because of difficulty understanding the written information? Do you have a phone at home? Do you have access to the internet? Do you have access to email? What is your height (in feet and inches)? What is your weight (in pounds)? Do you consider yourself to be Hispanic or Latino (choose one)? What race do you consider yourself to be? Select one or more of the following. What is your VA Priority Classification (check one): |
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