Which day did you start this survey?
Today M-D-Y
Last 4 digits of SSN (XXXX)
How many years old are you?
I am starting the 12-week cardiac rehabilitation program
I am finishing the 12-week cardiac rehabilitation program
HBCR Veteran Preferences - Please complete when enrolling into the program.
What is the highest level of education you have completed?
Eighth grade or less
Some high school
High school graduate/GED
Technical training
Some college/university
College/university graduate
Post-grad study
Prefer not to answer
What are the things you care about most in the SHORT-TERM? (mark all that apply)
If other, please describe:
What are the things you care about most in the LONG-TERM? (mark all that apply)
If other, please describe:
Are you interested in any services from Whole Health for Life? If so, we can place the consult for you. (mark all that apply)
Are you interested in any of the following strength-building services from a behavioral therapist in Health Psychology that works with lifestyle changes? (mark all that apply)
Are you interested in services from a registered dietitian who offers services related to detailed meal planning, cooking classes and other special needs? (mark one)
Yes
Maybe
No
Are you interested in conducting your remote visits using telehealth through VA Video Connect?
Yes. I have a device with camera and strong internet, and will not need help
Yes, I have a device with camera and strong internet, but will need help using it
Yes, but I would need the VA to provide me a video-capable device with strong internet
No, I only want to do my remote visits using telephone
Are you interested in learning more about our Annie program that sends text messages about healthy living?
Yes
No
If you are interested, which topics would you like to receive health messages about? (can select more than one)
Please provide your cell phone number if you would like us to sign you up for Annie today.
Annie text alerts occur at 9 AM on weekdays about cardiac rehab but can be changed (let us know if so).
If you are not interested, please leave blank. You may also try it out and opt out at any time.
To be completed if finishing program
Would you be interested in being contacted in the future about a paid research study that discusses your experiences with our program to help improve it?
Yes
No
If you checked off any problems, how DIFFICULT have these problems made it for you to do your work, take care of things at home or get along with other people? (mark one)
Extremely Difficult
Somewhat Difficult
Very Difficult
Not Difficult at All
Do any of the following cause moderate or severe stress? Select all that apply.
1
2
How hard is it for you to pay for the very basics like food, housing, medical care, and heating? Would you say it is:
Very hard
Somewhat hard
Not hard at all
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Which of the following statements best describes how physically active you have been during the last month, that is, done activities such as 15-20 minutes of brisk walking, swimming, general conditioning, or recreational sports?
Not at all active
A little active (1-2x/mo)
Fairly active (3-4x/mo)
Quite active (1-2x/wk)
Very active (3-4x/wk)
Extremely active (5x or more/wk)
Do you have any joint or muscle problems that significantly limits your ability to walk?
Yes
No
If you have pain with walking, how severe is it?
No Pain Hardly Notice Pain Noticed pain but it does interfere with activities Sometimes distracts me Distracts me, can do usual activities Interrupts some activities Hard to ignore, avoid usual activities Focus of attention, prevents doing daily activities Awful, hard to do anything Can't bear the pain, unable to do anything As bad as it could be, nothing else matters
Do you use any of these assistive devices to get around?
How often have you had angina, chest pain, or chest tightness in the past 4 weeks (on average)?
No Episodes
Less than once per week
Less than once per day, but more than once per week
Once per day or more
When you walk at an ordinary pace on the level ground, does this produce pain?
Yes
No
When you walk up hill or hurry, does this produce pain?
Yes
No
When you get any pain or discomfort in your chest when walking, what do you do? Mark all that apply
In general, would you say your health is:
Excellent
Very Good
Good
Fair
Poor
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?
Yes, Limited a lot
Yes, Limited a little
No, not limited at all
Climbing several flights of stairs?
Yes, Limited a lot
Yes, Limited a little
No, not limited at all
Accomplished less than you would like
No, None of the time
Yes, A little of the time
Yes, Some of the time
Yes, Most of the time
Yes, All of the time
Were limited in the kind of work or other activities.
No, None of the time
Yes, A little of the time
Yes, Some of the time
Yes, Most of the time
Yes, All of the time
Accomplished less than you would like.
No, None of the time
Yes, A little of the time
Yes, Some of the time
Yes, Most of the time
Yes, All of the time
Didn't do work or other activities as carefully as usual.
No, None of the time
Yes, A little of the time
Yes, Some of the time
Yes, Most of the time
Yes, All of the time
During the past 4 weeks, how much did pain interfere with your normal work(including both work outside the home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extremely
During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?
None of the time
A little of the time
Some of the time
Most of the time
All of the time
Compared to one year ago , how would you rate your physical health in general now?
Much worse
Slightly worse
About the same
Slightly better
Much better
Compared to one year ago , how would you rate your emotional problems (such as feeling anxious, depressed, or irritable) now?
Much worse
Slightly worse
About the same
Slightly better
Much better
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The following is a list of activities which increase in difficulty as you read down the page. Think carefully, then choose the first activity that, if you performed it for a period, would typically cause fatigue, shortness of breath, chest discomfort, or otherwise cause you to want to stop. If you do not normally perform a particular activity, try to imagine what it would be like if you did.
Eating, getting dressed, or working at a desk
Taking a shower, walking down 8 steps
Walking slowly on a flat surface for 1-2 blocks, moderate housework (vacuum, sweeping floors, carrying groceries)
Light yard work ( raking leaves, weeding, pushing power mower), painting, light carpentry
Walking briskly ( 4 miles in an hour), social dancing, washing a car
Playing 9 holes of golf carrying your own clubs, heavy carpentry, mow lawn with push mower
Heavy outdoor work (digging, spading soil), playing singles tennis carry 60 pounds
Move heavy furniture, jog slowly, climb stairs quickly, carry 20 pounds upstairs
Bicycling at a moderate pace, sawing wood, jumping rope (slowly)
Brisk swimming, bicycle up a hill, walking briskly uphill, jog 6 miles per hour
Cross country ski, play full court basketball
Running briskly, continuously (level grounds, 8 minutes per mile)
Any competitive activity with intermittent sprinting, running competitively, rowing, backpacking
Please select why you would be likely to stop (mark all that apply)
If other, please describe:
Predicted METs based on VSAQ?
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Do you use only extra-virgin olive oil for cooking, salad dressings, and spreads?
Yes
No
How many tablespoons of olive oil do you consume per day (including that used in frying, salads, meals eaten away from home, etc.)?
How many servings of vegetables/garden produce do you consume per day? [1 serving: 200 g or 7 ounces (consider side dishes as half a serving)]
How many fruit units (including natural fruit juices) do you consume per day?
How many servings of red meat, hamburgers, or meat products (ham, sausage, etc.) do you consume per week? (1 serving: 100 - 150 g or 3-5 ounces)
How many servings of butter, margarine, or cream do you consume per week? (1 serving: 12 g or tablespoon)
How many sugary beverages or sugar-sweetened fruit juices do you drink per week?
How many glasses of wine do you drink per day? (1 glass: 100 ml or 4 ounces)
How many servings of legumes do you consume per week? (1 serving: 150 g or 5 ounces). This includes beans and lentils.
How many servings of fish or shellfish do you consume per week? (1 serving: 3-5 ounces of fish, 4-5 pieces, or 7 ounces of seafood)
How many times per week do you consume commercial sweets or pastries (not homemade), such as cakes, cookies, sponge cake, or custard?
How many servings of nuts (including peanuts) do you consume per week? (1 serving: 30 g or 1 ounce)
Do you preferentially consume chicken, turkey or rabbit instead of beef, pork hamburgers or sausages?
Yes (may also select if vegetarian)
No
How many times per week do you consume vegetables, pasta, rice or other dishes seasoned with sofrito (sauce made with tomato and onion, leek or garlic and simmered in olive oil)?
How many times per week do you eat deep fried foods such as french fries, potato chips, and fried chicken?
How many times per week do you consume whole grain cereals and pasta?
How many servings of white bread do you consume per day? (1 serving: 75 g)
Do you preferentially add non-caloric artificial sweeteners to beverages (such as coffee or tea) instead of sugar?
Yes (or if you do not use any sweeteners at all)
No
How many times per week do you consume non-whole grain pasta or white rice?
Mediterranean Diet Scoring
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HBCR Medication Confidence Raw Score
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Do you smoke cigarettes or use tobacco every day, some days, or not at all ?
Every Day
Some Days
Not at all
Decline to answer
If you do not currently smoke, have you ever used tobacco?
Yes, Former User
Never
If you previously smoked tobacco, how long ago did you quit?
Less than 1 year ago 1 to 5 years ago 5 to 15 years ago 15 or more years ago
Do you want advice on how to quit smoking or tobacco use?
Yes No
How often did you have a drink containing alcohol in the past year?
Four or more times a week Two to three times per week Two to four times a month Monthly or less Never
How many drinks containing alcohol did you have on a typical day when you were drinking in the past year?
Ten or more drinks Seven to nine drinks Five or six drinks Three or four drinks One or two drinks Zero drinks
How often did you have six or more drinks on one occasion in the past year?
Daily or almost daily Weekly Monthly Less than monthly Never
Have you ever done any of these drugs in the past 3 months? If yes, select all that apply.