Patient Questionnaires BASELINE ASSESSMENT

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1 Patient Questionnaires BASELINE ASSESSMENT Page 1 of 25

2 Section: Study Entry Patient identification number Date of study entry D D M M Y Y Y Y GP Practice Number Researcher Initials Signature of Assessor Page 2 of 25

3 Patient Questionnaire 1: Employment, Housing, Health and Leisure (EHHaL) Question 1: Living arrangements 1a. Tell me about the place you live. Who do you live with? (Please tick as many that apply to you) Partner or spouse 1 [ ] Children (under 18) 2 [ ] Other adults including family and friends 3 [ ] Live alone 4 [ ] 1b.Please tick the type of accommodation you live in (please tick one) Parents home 5 [ ] Other family carers home 6 [ ] Lives independently, without any paid support 7 [ ] Supported group living (shared tenancy, with paid support) 8 [ ] Supported living individual (single tenancy, with paid support) 9 [ ] Residential care (registered home) 10 [ ] Nursing home 11 [ ] NHS accommodation 12 [ ] Other accommodation [ ] 2. If you live in supported accommodation or residential care how much support do you get each week? (Please tick one) Part- support (less than daily) 1 [ ] Part- support (daily) 2 [ ] 24 hour support, sleep-in nights 3 [ ] 24 hour support, including wake at night 4 [ ] Organisation providing support package.. Page 3 of 25

4 3. Are you in paid employment? Are you in education, training or retired? What employment type/s do you have? (Please tick as many that apply to you) None 0 [ ] Part paid employment (30 hours / week or less) 1 [ ] Full paid employment (more than 30 hours / week) 2 [ ] Paid employment with paid support / employment training 3 [ ] Employed, but only paid up to the allowed limit without affecting benefits 4 [ ] Voluntary work 5 [ ] Education including school, college, or other training 6 [ ] Internship 7 [ ] Looking after home and family 8 [ ] Retired from paid work 9 [ ] Other, please give details [ ] 4. Is there anyone who helps you with daily activities like shopping, cooking, cleaning, looking after yourself or leisure activities? (Please tick) Yes (Please complete the table below) 1 [ ] No (if no please go to question 5) 0 [ ] If yes, please complete the table below for all of the people who help you with daily activities like shopping, cooking, cleaning, looking after yourself or leisure activities. Please tick as many that apply to you. Page 4 of 25

5 Who helps you with daily activities? (please tick) Friend YES [ ] NO [ ] Is this person employed? (Please tick) No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] Thinking about a typical week in the last 6 months, how many hours of care or support were provided by this person? hours per week Thinking about a typical week in the last 6 months, approximately how many hours per week does this person spend helping you with the following activities? Shopping for food hours per week Cooking hours per week Retired from paid work [ ] Exercising or playing sports In education [ ] hours per week Other, please give details Other leisure activities.. hours per week Partner or spouse YES [ ] No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] hours per week Shopping for food hours per week Cooking NO [ ] Retired from paid work [ ] hours per week In education [ ] Exercising or playing sports Other, please give details hours per week.. Other leisure activities hours per week Page 5 of 25

6 Who helps you with daily activities? (please tick) Mental health worker YES [ ] Is this person employed? (Please tick) No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] Thinking about a typical week in the last 6 months, how many hours of care or support were provided by this person? hours per week Thinking about a typical week in the last 6 months, approximately how many hours per week does this person spend helping you with the following activities? Shopping for food hours per week Cooking NO [ ] Retired from paid work [ ] hours per week In education [ ] Other, please give details Exercising or playing sports hours per week.. Other leisure activities hours per week Support worker YES [ ] NO [ ] No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] Retired from paid work [ ] hours per week Shopping for food hours per week Cooking hours per week In education [ ] Other, please give details.. Exercising or playing sports hours per week Other leisure activities hours per week Page 6 of 25

7 Who helps you with daily activities? (please tick) Family Member YES [ ] NO [ ] Is this person employed? (Please tick) No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] Retired from paid work [ ] Thinking about a typical week in the last 6 months, how many hours of care or support were provided by this person? hours per week Thinking about a typical week in the last 6 months, approximately how many hours per week does this person spend helping you with the following activities? Shopping for food hours per week Cooking hours per week If YES please give details In education [ ] Other, please give details Exercising or playing sports hours per week.. Other leisure activities hours per week Other YES [ ] NO [ ] No [ ] Part paid employment (30 hours / week or less) [ ] Full paid employment (more than 30 hours / week) [ ] Retired from paid work [ ] hours per week Shopping for food hours per week Cooking hours per week If YES please give details In education [ ] Other, please give details Exercising or playing sports hours per week.. Other leisure activities hours per week. Page 7 of 25

8 5. Have you accessed stop smoking services in the last 6 months? (Please tick) Yes 1 [ ] No (if no please go to question 8) 0 [ ] Not Applicable (please go to question 8) 2 [ ] 6. Which of the following stop smoking services have you used? (Please tick as many that apply to you). Please give details of the total number of contacts (in the last 6 months) in the box provided. One-to-one meetings with a trained advisor 0 [ ] Group meetings with a trained advisor 1 [ ] Quit smoking application (app) on your phone or computer 2 [ ] Quit kit (a box with practical tools and advice) 3 [ ] Other, please give details. 4 [ ] 7. In the last 6 months, have you been prescribed or used any nicotine replacement therapies (NRT) such as gum, patches, inhalers, lozenges, spray or e-cigarettes? Yes 1 [ ] No 0 [ ] If yes, please complete below for all of the types of nicotine replacement therapies (NRT) you have used in the last 6 months. Leave blank if you have not used that type of NRT Type of nicotine replacement therapy (NRT) For how many months have you taken the NRT? How often do you buy or have a prescription filled for? Please tick one Gum Once a week [ ] Once every two weeks [ ] Once a month [ ] Once every two months [ ] Less than once every two months [ ] Only got it once [ ] Do you, your family or carer pay for the NRT, or is it free to you on the NHS? Please tick one Free on the NHS Yes [ ] No [ ] If no, average amount you pay per month in and p: _. Page 8 of 25

9 Patches Once a week [ ] Once every two weeks [ ] Once a month [ ] Once every two months [ ] Less than once every two months [ ] Only got it once [ ] Inhalers Once a week [ ] Tablets/ lozenges Once every two weeks [ ] Once a month [ ] Once every two months [ ] Less than once every two months [ ] Only got it once [ ] Once a week [ ] Once every two weeks [ ] Once a month [ ] Once every two months [ ] Less than once every two months [ ] Only got it once [ ] Spray Once a week [ ] Electronic cigarettes known as e-cigarettes Once every two weeks [ ] Once a month [ ] Once every two months [ ] Less than once every two months [ ] Only got it once [ ] Once a week [ ] Once every two weeks [ ] Once a month [ ] Once every two months [ ] Free on the NHS Yes [ ] No [ ] If no, average amount you pay per month in and p: _. Free on the NHS Yes [ ] No [ ] If no, average amount you pay per month in and p: _. Free on the NHS Yes [ ] No [ ] If no, average amount you pay per month in and p: _. Free on the NHS Yes [ ] No [ ] If no, average amount you pay per month in and p: _. Free on the NHS Yes [ ] No [ ] If no, average amount Page 9 of 25

10 Less than once every two months [ ] Only got it once [ ] you pay per month in and p: _. 8. Have you accessed alcohol services in the last 6 months? (Please tick) Yes 1 [ ] No (if no please go to question 10) 0 [ ] Not Applicable (please go to question 10) 2 [ ] 9. Which of the following alcohol services have you received? (Please tick as many that apply to you). Please specify the total number of contacts (in the last 6 months) in the box provided. One-to-one meetings 0 [ ] Group meetings 1 [ ] Alcohol rehabilitation services 2 [ ] Cognitive behavioural therapy (CBT) 3 [ ] Family therapy 4 [ ] Other, please give details.. 5 [ ] 10. Have you accessed weight management services in the last 6 months? (Please tick) Yes 1 [ ] No (if no please go to question 12) 0 [ ] Not Applicable (please go to question 12) 2 [ ] Page 10 of 25

11 11a. Which of the following weight management services have you received? (Please tick as many that apply to you). Please specify the total number of contacts (in the last 6 months) in the box provided. One-to-one meetings with a trained advisor 0 [ ] Group meetings with a trained advisor 1 [ ] Slimming world and their food optimising plan 2 [ ] Weight watchers 3 [ ] Dietician 4 [ ] Other, please give details.. 5 [ ] 11b. Was this free on the NHS or did you, your family or carer pay for this (out-of-pocket)? Free on the NHS 1 [ ] Paid for out of pocket 0 [ ] 12. Have you accessed diabetes management services in the last 6 months? (Please tick) Yes 1 [ ] No (if no please go to Section B) 0 [ ] Not Applicable (please go to Section B) 2 [ ] 13. Which of the following diabetes management services have you received? (Please tick as many that apply to you). Please specify the total number of contacts (in the last 6 months) in the box provided. One-to-one meetings with a trained advisor 0 [ ] Group meetings with a trained advisor (eg Diabetes UK voluntary groups) 1 [ ] Newsletters 2 [ ] Diabetes UK Careline 3 [ ] Online communities and forums (eg 4 [ ] Diabetes UK tracker application (app) on your phone 5 [ ] Eye tests for diabetic retinopathy 6 [ ] Other, please give details.. 7 [ ] Page 11 of 25

12 SECTION B: OTHER DAYTIME ACTIVITIES Please complete below for all of the types of activities and day services that you have used in the last 6 months. Leave blank if you have not participated in that activity or used that type of service Service Name of service Who runs the service? Leisure centre or gym 1 NHS 2 Local authority 3 Voluntary organisation 4 Private 5 Community group 6 Other, please give details How many months have you been using the service? In the average week, how many hours do you use the service? Sports club or other leisure activities (e.g. football, netball, tennis, horse-riding) please specify Day centre Voluntary work Adult education Drop-in centre Social club One-to-one activities (e.g. Goldhurst: please give details) Other service (please give details) Page 12 of 25

13 Patient Questionnaire 2: International Physical Activity Questionnaire (IPAQ) The questions are about the you spent being physically active in the last 7 days. They include questions about activities you do at work, as part of your house work, to get from place to place, and in your spare for recreation, exercise or sport. Please answer each question even if you do not consider yourself to be an active person. In answering the following questions, vigorous physical activities refer to activities that take hard physical effort and make you breathe much harder than normal. moderate activities refer to activities that take moderate physical effort and make you breathe somewhat harder than normal. 1a. During the last 7 days, on how many days did you do vigorous physical activities like heavy lifting, digging, aerobics, or fast bicycling? Think about only those physical activities that you did for at least 10 minutes at a. days per week or 1b. How much in total did you usually spend on one of those days doing vigorous physical activities? hours minutes None 2a. Again, think only about those physical activities that you did for at least 10 minutes at a. During the last 7 days, on how many days did you do moderate physical activities like carrying light loads, bicycling at a regular pace, or doubles tennis? Do not include walking. days per week or 2b. How much in total did you usually spend on one of those days doing moderate physical activities? hours minutes None Page 13 of 25

14 3a. During the last 7 days, on how many days did you walk for at least 10 minutes at a? This includes walking at work and at home, walking to travel from place to place, and any other walking that you did solely for recreation, sport, exercise or leisure. days per week or None 3b. How much in total did you usually spend walking on one of those days? hours minutes The last question is about the you spent sitting on weekdays while at work, at home, while doing course work and during leisure. This includes spent sitting at a desk, visiting friends, reading, travelling on a bus or sitting or lying down to watch television. 4. During the last 7 days, how much in total did you usually spend sitting on a week day? hours minutes Page 14 of 25

15 Patient Questionnaire 3: EQ-5D-5L Health Questionnaire Under each heading, please tick the ONE box that best describes your health TODAY MOBILITY I have no problems in walking about I have slight problems in walking about I have moderate problems in walking about I have severe problems in walking about I am unable to walk about SELF-CARE I have no problems washing or dressing myself I have slight problems washing or dressing myself I have moderate problems washing or dressing myself I have severe problems washing or dressing myself I am unable to wash or dress myself USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities) I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities Page 15 of 25

16 PAIN / DISCOMFORT I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort ANXIETY / DEPRESSION I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed Page 16 of 25

17 The best health We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100. you can imagine means the best health you can imagine. 0 means the worst health you can imagine. Mark an X on the scale to indicate how your health is TODAY. Now, please write the number you marked on the scale in the box below YOUR HEALTH TODAY = The worst health you can imagine Page 17 of 25

18 Patient Questionnaire 4: The Warwick-Edinburgh Mental Well-being Scale (WEMWBS) Below are some statements about feelings and thoughts. Please tick the box that best describes your experience of each over the last 2 weeks STATEMENTS I ve been feeling optimistic about the future None of the Rarely Some of the Often All of the I ve been feeling useful I ve been feeling relaxed I ve been feeling interested in other people I ve had energy to spare I ve been dealing with problems well I ve been thinking clearly I ve been feeling good about myself I ve been feeling close to other people I ve been feeling confident I ve been able to make up my own mind about things I ve been feeling loved I ve been interested in new things I ve been feeling cheerful Page 18 of 25

19 Patient Questionnaire 5: Medical Outcomes Study: Social Support Survey (MOS-SSS) 1. About how many close friends and relatives do you have (people you feel at ease with and can talk to about what is on your mind)? People somes look to others for companionship, assistance or other types of support. How often is each of the following kinds of support available to you if you need it? Please tick the appropriate box for each statement Someone you can count on to listen when you need to talk None of the A little of the Some of the Most of the All of the Someone to give you information to help you understand a situation Someone to give you good advice about a crisis Someone to confide in or talk to about yourself or your problems Someone whose advice you really want Someone to share your most private worries and fears with Someone to turn to for suggestions about how to deal with a personal problem Someone who understands your problems Someone to help you if you were confined to bed Someone to take you to the doctor if you needed it Someone to prepare your meals if you were unable to do it yourself Someone to help with daily chores if you were sick Someone who shows you love and affection Someone to love and make you feel wanted Page 19 of 25

20 None of the A little of the Some of the Most of the All of the Someone who hugs you Someone to have a good with Someone to get together with for relaxation Someone to do something enjoyable with Someone to do things with to help you get your mind off things This section asks you questions on who you would go to for different kinds of support. Please tick the box next to each person you would go to for support. If you would go to a family member please say who this person is (for example son, mother, sister) Would you go to any of the following people to talk about problems? Friend Partner or spouse Support worker Mental health key worker Family member Other person please give details.. please give details.. Nobody Would you ask any of the following people to go to an important appointment with you? Friend Spouse or partner Support worker Mental health key worker Page 20 of 25

21 Family member Other person please give details.. please give details.. Nobody Would you go to any of the following people to do something fun with? Friend Spouse or partner Support worker Mental health key worker Family member Other person please give details.. please give details.. Nobody Would you go to any of the following people to feel love or affection? Friend Spouse or partner Support worker Mental health key worker Family member Other person please give details.. please give details.. Nobody Page 21 of 25

22 Patient Questionnaire 6: Scale to Assess Therapeutic Relationships in Community Mental Health Care (STAR) If you have a mental health key worker please complete this questionnaire. If you do not have a mental health key worker please go to Patient Questionnaire 7. Please tick the box that best describes your relationship with your mental health key worker Never Rarely Some s Often Always My mental health worker speaks with me about my personal goals and thoughts about treatment My mental health worker and I are open with one another My mental health worker and I share a trusting relationship I believe my mental health worker withholds the truth from me My mental health worker and I share an honest relationship My mental health worker and I work towards mutually agreed upon goals My mental health worker is stern with me when I speak about things that are important to me and my situation My mental health worker and I have established an understanding of the kind of changes that would be good for me My mental health worker is impatient with me My mental health worker seems to like me regardless of what I do or say We agree on what is important for me to work on I believe my mental health worker has an understanding of what my experiences have meant to me Page 22 of 25

23 Patient Questionnaire 7: Morisky Scale of Adherence (MMS): Psychiatric Medications Please answer the following questions based on your personal experiences of taking ANTIPSYCHOTIC MEDICATION, ANTIDEPRESSANT MEDICATION, MOOD STABILISERS or any other medication for your mental health YES NO Do you somes forget to take your psychiatric medication? People somes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your psychiatric medication? Have you ever cut back or stopped taking your medications without telling your doctor because you felt worse when you took it? When you travel or leave home, do you somes forget to bring along your psychiatric medication? Did you take your psychiatric medication yesterday? When you feel like your psychiatric symptoms are under control, do you somes stop taking your medicine? Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? Never/ Rarely Once in a while Some s Usually All the How often do you have difficulty remembering to take all your psychiatric medications? Page 23 of 25

24 Patient Questionnaire 8: Morisky Scale of Adherence (MMS) - CVD preventative medications Please answer the following questions based on your personal experiences of taking STATINS, ANTIHYPERTENSIVES, METFORMIN, STOP-SMOKING MEDICATION and/or DIABETIC medications YES NO Do you somes forget to take your medications? People somes miss taking their medicines for reasons other than forgetting. Thinking over the past 2 weeks, were there any days when you did not take your medications? Have you ever cut back or stopped taking your medications without telling your doctor because you felt worse when you took it? When you travel or leave home, do you somes forget to bring along your medication? Did you take your medications yesterday? When you feel like your symptoms are under control, do you somes stop taking your medication? Taking medicine every day is a real inconvenience for some people. Do you ever feel hassled about sticking to your treatment plan? Never/ Rarely Once in a while Some s Usually All the How often do you have difficulty remembering to take all your medications? Page 24 of 25

25 End of Questionnaires Page 25 of 25

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