Better Choice Better Health: One year follow-up survey

Thank you for taking your time to complete this survey. We hope you enjoyed Better Choices Better Health workshop you attended last year.

Question Title

* 1. ID Number (Enter the ID number provided by your workshop leader)

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* 2. Today’s Date:

Date

Date

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* 3. In the past 6 months, how many TIMES did you visit a physician? Do not include visits while in the hospital or the hospital emergency department (also called an emergency room or ER).

Visits

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* 4. In the past 6 months, how many TIMES did you go to a hospital emergency department (also called an emergency room or ER)?

Times

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* 5. In the past 6 months, how many TIMES were you hospitalized one night or longer?

Times

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* 6. How many total NIGHTS did you spend in the hospital in the past 6 months?

Nights

Thank you for your help!

Better Choices Better Health – Ke Ola Pono

A project of Hawai‘i’s Healthy Aging Partnership