needs assessment questionnaire

WEB-BASED PATIENT-REPORTED OUTCOMES CAPTURE SYSTEM – NEEDS, ACCEPTANCE AND READINESS ASSESSMENT (WPROCS – NARA)

NEEDS ASSESSMENT QUESTIONNAIRE A. Your health needs and status in the last three months 1. In the last three months, how many times did you initiate a consultation outside scheduled check-ups with your doctor for health advice or care? [1] None [2] 1-2 [3] 3-5 [4] More than 5 2. In the last three months, how many times did you need care right away in a doctor’s clinic or emergency room? [1] None [2] 1-2 [3] 3-5 [4] More than 5 3. In the last three months, how many times did you need to stay as a patient in the hospital overnight or longer? [1] None [2] 1-2 [3] 3-5 [4] More than 5 4. Using any number from 0 to 10, where 0 is the worst and 10 is the best health condition possible, how would you rate your overall health condition in the last three months? _____ 5. Using any number from 0 to 10 where 0 is the worst and 10 is the best health condition possible, how would you rate your mental or emotional health in the last three months? _____ 6. Using any number from 0 to 10, where 0 is none and 10 is the maximum home healthcare, assistance or nursing, possible, how would you rate your need for home healthcare, assistance or nursing? _____ 7. Do you need help with your personal care needs such as eating, dressing, or getting around the house?

DEVELOPMENT AND VALIDATION OF WPROCS – NARA QUESTIONNAIRES BACORRO, WR, et al

[1] No [2] Yes 8. Do you need help with your routine needs such as everyday household chores, doing necessary business, shopping or getting around for other purposes? [1] No [2] Yes 9. Do you have a tracheostoma or use a tracheostomy tube? [1] No [2] Yes B. Your symptoms and medication 1. Do you have any of these symptoms? (Check all that apply.) [ ] Pain [ ] Fatigue [ ] Nausea [ ] Disturbed sleep [ ] Feeling of being distressed or upset [ ] Shortness of breath [ ] Problem with remembering things [ ] Lack of appetite [ ] Feeling drowsy or sleepy [ ] Dry mouth [ ] Feeling sad [ ] Vomiting [ ] Numbness or tingling [ ] None of the above 2. Of the following symptoms, which do you find most distressing? (Choose three and rank them accordingly, 1 as the most distressing.) [ ] Pain [ ] Fatigue [ ] Nausea [ ] Disturbed sleep [ ] Feeling of being distressed or upset [ ] Shortness of breath [ ] Problem with remembering things [ ] Lack of appetite [ ] Feeling drowsy or sleepy [ ] Dry mouth


[ ] Feeling sad [ ] Vomiting [ ] Numbness or tingling 3. Do you take pain medications? [1] No [2] Yes 4. How do you take your pain medications? [ ] By mouth [ ] By patch [ ] By veins [ ] Others, please specify: ___________________ 5. For which other symptoms do you take medications? (Check all that apply.) [ ] None [ ] Fatigue [ ] Nausea [ ] Disturbed sleep [ ] Feeling of being distressed or upset [ ] Shortness of breath [ ] Problem with remembering things [ ] Lack of appetite [ ] Feeling drowsy or sleepy [ ] Dry mouth [ ] Feeling sad [ ] Vomiting [ ] Numbness or tingling 6. How do you take these medications? (Check all that apply.) [ ] By mouth [ ] By patch [ ] By veins [ ] Others, please specify: _______________ 7. Do any of these medications require a prescription? [1] No [2] Yes C. Your feeding and nutrition


1. By your estimate, have you had any weight change in the last three months? [1] No [2] Yes, weight loss [3] Yes, weight gain 2. Not including problems with appetite, do you have any problems with eating? [1] No [2] Yes 3. Do you use a tube for feeding? [1] No [2] Yes, nasogastric tube [3] Yes, gastrostomy tube D. Your healthcare and support for the last three months 1. Outside the hospital or clinics, who provides you professional health care and advice? [1] Caregiver [2] Personal nurse [3] Others, please specify: _______________________ [4] None 2. Using any number from 0 to 10, where 0 is the worst and 10 is the best social support possible, how would you rate the social support you get from your family? _______ 3. Using any number from 0 to 10, where 0 is the worst and 10 is the best social support possible, how would you rate the social support you get from your friends? _______ 4. In the last three months, how often was it easy for you to get care or advice? [1] Always [2] Usually [3] Sometimes [4] Never 5. In the last three months, when you needed care right away, how often did you get care or advice as soon as you needed it? [1] Always [2] Usually [3] Sometimes [4] Never


6. Using any number from 0 to 10, where 0 is the worst and 10 is the best primary doctor possible, how would you rate your primary doctor? _______ E. Your access to healthcare 1. How long does it take you to reach the closest clinic or hospital? [1] 15 minutes or less [2] Between 15 minutes to 30 minutes [3] Between 30 minutes to 1 hour [4] Between 1 hour to 2 hours [5] More than 2 hours 2. How long does it take you to reach UST Hospital? [1] 15 minutes or less [2] Between 15 minutes to 30 minutes [3] Between 30 minutes to 1 hour [4] Between 1 hour to 2 hours [5] More than 2 hours 3. How long does it take you to reach any other clinic or hospital where your primary doctor works? [1] 15 minutes or less [2] Between 15 minutes to 30 minutes [3] Between 30 minutes to 1 hour [4] Between 1 hour to 2 hours [5] More than 2 hours 4. How do you move around? [1] Walking, by myself [2] Walking, by myself, with cane or walker [3] Walking, with assistance [4] Wheelchair, by myself [5] Motorized wheelchair, by myself [6] Wheelchair, with assistance 5. Do you have any disability? (Check all that apply.) [ ] Blindness [ ] Hearing impairment [ ] Mobility impairment [ ] Speech impairment [ ] Other, please specify: ______________________