How important is your behavioral, mental, or emotional health to your overall physical health? |
Five-point Likert scale items from “not important” to “extremely important” |
How comfortable would you feel being asked about or even getting help for your behavioral, mental, or emotional health issues here at the clinic? |
Five-point Likert scale items from “not at all comfortable” to “extremely comfortable” |
If you had a behavioral, mental, or emotional health concern, which of the following would you prefer |
To get help here in the clinic from a team member; To get help here in the clinic, but only from my doctor; To get help here in the clinic from a behavioral health clinician It depends; To get a referral to a specialist outside the clinic |
To what extent are your behavioral health needs met in this clinic? |
Five-point Likert scale items from “not at all” to “completely” |
Demographics |
|
Age |
17 or below; 18-20; 21-29; 30-39; 40-49; 50-59; 60-69; 70 or above |
Sex |
Female; Male; Transgender; Other (specify) |
Race/ethnicity |
Asian; American Indian or Alaskan Native; Black or African American; Hispanic or Latino; Native Hawaiian or Pacific Islander; White; Other (specify) |
Have you ever received treatment for any of the following problems? (Select all that apply) |
Diabetes; Hypertension; COPD; Asthma; Depression; Anxiety/stress; Alcohol or drug use |
Are you currently under our care for any of the following problems? (Select all that apply) |
Diabetes; Hypertension; COPD; Asthma; Depression; Anxiety/stress; Alcohol or drug use |
If you checked “yes” to diabetes or hypertension, how much of an impact do behavioral, mental, or emotional health issues have on your condition and your ability to manage it? |
Five-point Likert scale items from “no impact” to “major impact” |