Bridge2Health Intake Assessment Please answer the following questions to the best of your ability. This information will be kept confidential. Participation is voluntary. Name First Last Email Why do you want to participate in the Bridge2 Health Program? This applies if you are enrolled in Health 360 or Create Better Health.Rate your health status on a scale from 1 to 10 with 1 being the least healthy and 10 being the most healthy. Please select the number that best fits with your current physical activity and eating habits. 1 2 3 4 5 6 7 8 9 10 Eating healthy can be described as eating within your daily calorie needs and including a variety of foods such as fruits, vegetables and whole grains. Please mark the statement that best describes your current eating habits. I have not been eating healthy and I do not plan on changing my eating habits in the near fut I plan to eat healthier in the next 6 months. I plan to eat healthier in the next month. I have been eating healthier in the last 6 months. I have been eating healthy for more than 6 months. Being physically active can be described as doing activities such as walking, playing a sport, dancing etc. for at 150 minutes a week. For example, jogging 5 times a week for 30 minutes each time. Please mark the statement that best describes your current level of physical activity. I am not physically active now and I do not plan to do any physical activity in the near future. I plan to become more physically active in the next 6 months.Second Choice I plan to become more physically active in the next month. I have been more physically active in the last 6 months. I have been physically active for more than 6 months. How confident are you that you can make changes now? Please mark the statement that best describes your confidence in making the following changes. I can get physical activity more often.I can get physical activity more often. Strongly agree Agree Not Sure Disagree Strongly Disagree Does Not Apply I can be physically active for longer periods of time.I can be physically active for longer periods of time. Strongly agree Agree Not Sure Disagree Strongly Disagree Does Not Apply I can eat more healthy foods.I can eat more healthy foods. Strongly agree Agree Not Sure Disagree Strongly Disagree Does Not Apply I can overeat less often.I can overeat less often. Strongly agree Agree Not Sure Disagree Strongly Disagree Does Not Apply What might help you be more confident in making the changes described above?What is one health goal that you would like to work toward in the next 30 days?What are some challenges or barriers you may face in your effort to make healthy lifestyle changes? Needs Assessment Thinking about your current circumstances, please answer the following questions to best describe your situation. Your answers will be used by the Bridge2Health team to evaluate your needs and determine the best resources for you. This information will be kept confidential. Participation is voluntary. Do you have health insurance? Yes No How do you receive your health insurance? (check all that apply) Insured through work Individual health plan (bought directly by myself or a family member) Medicare Medicaid Indigent County Card Good Health Card Does not apply Other 11. Other How would you rate the following issues for your household? (check all that apply) Access to foodAccess to food Serious Problem Moderate Problem Mild Problem Not a Problem Access to healthy food (ex. fruits, vegetables, low sodium, lean meats)Access to healthy food (ex. fruits, vegetables, low sodium, lean meats) Serious Problem Moderate Problem Mild Problem Not a Problem Knowledge of healthy eating habits (ex. serving sizes, calories, nutrients)Knowledge of healthy eating habits (ex. serving sizes, calories, nutrients) Serious Problem Moderate Problem Mild Problem Not a Problem Availability of jobsAvailability of jobs Serious Problem Moderate Problem Mild Problem Not a Problem Access to job training opportunitiesAccess to job training opportunities Serious Problem Moderate Problem Mild Problem Not a Problem Access to adult education (ex. GED)Access to adult education (ex. GED) Serious Problem Moderate Problem Mild Problem Not a Problem Access to healthcareAccess to healthcare Serious Problem Moderate Problem Mild Problem Not a Problem Health of household membersHealth of household members Serious Problem Moderate Problem Mild Problem Not a Problem What are your main healthcare needs? (check all that apply) Primary healthcare Pediatric (child) healthcare Dental care Chronic condition (ex. heart disease, diabetes) Health education and chronic disease prevention Nutrition and exercise programs Health screening services Does not apply Other 13. Other In the past 12 months, have you had any of the following concerns about food? (check all that apply) I was worried that my food would run out before I would be able to buy more Food I bought didn't last and I didn't have the money to buy more I could not afford to eat balanced and nutritious meals (a variety of foods with recommended vitamins and nutrients) I ate less or skipped meals because there wasn't enough money for food I was hungry but did not eat because there wasn't enough money for food I had enough food to eat but not the kinds of foo that I wanted Does not apply Other 14. Other What are things that make it difficult for you to find and/or keep work? (check all that apply) Need job experience Need job training Need job opportunities Do not have a high school diploma or GED Do not have a college degree Disability Criminal record Does not apply Other 15. Other Do you have an interest in any of the following? (check all that apply) Nutrition and exercise programs Health education and chronic disease prevention programs Food assistance Adult education (ex. GED) Job skills training Employment assistance Other 16. Other
