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 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 about a paid research study to help improve our program?
Yes
No
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.
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
1
2
Do any of the following cause a lot of stress? Select all that apply.
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
View equation
View equation 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
The following is a list of activities which increase in difficulty as you read down the page.
Choose the first activity that may cause you to stop early because of shortness of breath, chest pain, or other reasons.
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?
View equation Please describe the way in which most of your meals are prepared
I prepare most of my meals myself
Someone I live with prepares my meals for me
I use a meal delivery service like meals on wheels
I eat mostly restaurant or packaged food
None of the above
What type of oil or fat do you mostly use for cooking, food dressing, and spreads?
Olive oil
Other vegetable oil (not olive oil)
Butters, margarines, mayonnaise, or lard
Other or none
View equation
HBCR Medication Confidence Raw Score
View equation Would you like to talk with a pharmacist to help you better understand your medications?
Yes
No
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
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 at a time do you normally have?
Ten or more drinks
Seven to nine drinks
Five or six drinks
Three or four drinks
One or two 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.