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My Health Habits Pretest and Posttest

Download My Health Habits Pretest and Posttest pdf document (163k, 8 pages) handout.

FOR INTERNAL USE ONLY (For Strategy a, b, and )

Pretest Start Date (MM/DD/YYYY):

Posttest End Date (MM/DD/YYYY):

Name of person administering the “My Health Habits” questionnaire:

Project Location:

  • Clinic
  • Community-based organization
  • Other

Patient identification (ID) number:

Participant Information

  1. Today's date (MM/DD/YYYY):
  2. Age (in years):
  3. Gender: Male Female
  4. Place of birth: City State Country
  5. Do you consider yourself Latino or Hispanic? Yes, No
  6. Which race do you consider yourself to be? Alaska Native, American Indian, Asian, Black or African American, Native Hawaiian or other Pacific Islander, White
  7. Time living in the United States: Years, Months
  8. Preferred Language: English, Spanish, Both
  9. Have you been told by a health care professional that you have diabetes? Yes, No, Don't know
  10. Does your family have a history of heart disease? Yes, No, Don't know

Salt and Sodium

How often do you do the following things? Mark your answer with an X.

  1. Do you buy fresh vegetables instead of canned vegetables? Never, Sometimes, Most of the time, All the time
  2. Do you use bouillon cubes when you cook? Never, Sometimes, Most of the time, All the time
  3. Do you read labels to choose foods with a low-sodium content? Never, Sometimes, Most of the time, All the time
  4. Do you add salt to fruit? Never, Sometimes, Most of the time, All the time
  5. Do you add salt to the water when you cook beans, rice, pasta, or vegetables? Never, Sometimes, Most of the time, All the time
  6. Do you buy meats such as ham, bologna, hotdogs, or sausage? Never, Sometimes, Most of the time, All the time
  7. Do you use a saltshaker at the table? Never, Sometimes, Most of the time, All the time
  8. Do you fill the saltshaker with a mixture of herbs and spices instead of salt? Never, Sometimes, Most of the time, All the time
  9. Do you choose fruits and vegetables instead of potato chips, french fries, and pork rinds? Never, Sometimes, Most of the time, All the time

Cholesterol and Fat

How often do you do the following things?  Mark your answer with an X.

  1. Do you drink fat-free milk or 1% milk? Never, Sometimes, Most of the time, All the time
  2. Do you eat low-fat cheese? Never, Sometimes, Most of the time, All the time
  3. Do you use vegetable oil spray to grease baking pans and skillets instead of using lard or butter? Never, Sometimes, Most of the time, All the time
  4. Do you read the food label to help you choose foods lower in saturated fat, trans fat, and cholesterol? Never, Sometimes, Most of the time, All the time
  5. Do you remove the skin before cooking chicken? Never, Sometimes, Most of the time, All the time
  6. Do you drain the fat and throw it away when you cook ground meat? Never, Sometimes, Most of the time, All the time
  7. Do you choose fat-free or low-fat salad dressing or mayonnaise? Never, Sometimes, Most of the time, All the time
  8. Do you use oil to prepare your food instead of using lard? Never, Sometimes, Most of the time, All the time

Weight Management

How often do you do the following things?  Mark your answer with an X.

  1. Do you read labels to choose foods lower in calories? Never, Sometimes, Most of the time, All the time
  2. Do you bake or grill chicken or other foods instead of frying them? Never, Sometimes, Most of the time, All the time
  3. Do you serve more vegetables on your plate than you do meat? Never, Sometimes, Most of the time, All the time
  4. Do you serve yourself large portions of food? Never, Sometimes, Most of the time, All the time
  5. Do you drink water instead of regular soda? Never, Sometimes, Most of the time, All the time
  6. Do you have drinks with sugar, such as powdered drinks, lemonade, or other drinks? Never, Sometimes, Most of the time, All the time
  7. Do you eat fruits instead of desserts or snacks that contain high amounts of sugar? Never, Sometimes, Most of the time, All the time
  8. Do you eat more when you feel stressed? Never, Sometimes, Most of the time, All the time

Physical Activity

Mark your answer with an X.

  1. Do you do any type of physical activity at your job? Yes, No
  2. Not including what you do at your job, do you do any other physical activity? Yes, No. If no, GO TO SMOKING. If yes, answer the following questions.
    1. What type of physical activity do you do? (You may select more than one answer.) Walking, Aerobic exercise, Playing sports, Other(please specify):
    2. How often do you do physical activity? Rarely (1 day a week), Several times a week (2 to 6 days a week), Every day
    3. How many minutes per day do you do physical activity? Less than 30 minutes, 30 to 59 minutes, 60 minutes or more

Smoking

Mark your answer with an X.

  1. Do you smoke? Yes, No
  2. Does anyone else smoke in your family? Yes, No
  3. Do you allow people to smoke in your home? Yes, No

Alcohol

Mark your answer with an X.
Note: One drink is one beer (12 ounces) OR one glass of wine (5 ounces) OR  1½ ounces of spirits (liquor or whiskey, straight or in a mixed drink). Drinking may occur every day, some days, or just on the weekend.

  1. Do you drink alcohol? Yes, No. If no, GO TO KNOWLEDGE. If yes, answer the following questions.
    1. How often do you drink? Rarely (on special occasions), Occasionally (once a month), Once a week, Regularly (several times a week), Every day
    2. When you drink, how many drinks do you have per occasion? One to two drinks, Occasionally (once a month), Once a week
    3. How often do you drink more than three drinks in one day? Never (on special occasions), Once or twice a week, Three to six times per week, Three to six times per week

Knowledge

Mark your answer with an X.

  1. Can a high waist measure increase your risk of heart disease? Yes, No, Don't know
  2. Can the Body Mass Index (BMI) chart tell you if you are overweight? Yes, No, Don't know
  3. Does your liver make all the cholesterol your body needs to keep you healthy? Yes, No, Don't know
  4. Can eating foods that are high in sodium increase your risk for high blood pressure? Yes, No, Don't know
  5. Does lard have a low amount of saturated fat? Yes, No, Don't know
  6. Can eating too much saturated fat and trans fat raise your cholesterol level? Yes, No, Don't know
  7. Is a blood pressure of 140/90 mmHg considered high? Yes, No, Don't know
  8. Can being overweight or obese put you at risk for developing high blood cholesterol? Yes, No, Don't know
  9. Is being physically active a way to reduce your risk for heart disease? Yes, No, Don't know
  10. Only people with high blood cholesterol should follow a heart healthy diet. Yes, No, Don't know
  11. Can nonsmokers die from secondhand smoke? Yes, No, Don't know
  12. Is having a fasting blood sugar of  126mg/dL or higher considered diabetes? Yes, No, Don't know
  13. Is having a waist measurement greater than  35 inches healthy for a woman? Yes, No, Don't know
  14. How confident are you in your ability to cook heart healthy foods? I am not confident, I am somewhat confident, I am confident, I am very confident.

A Day With the Ramírez Family

People act in different ways when they learn that they need to make changes to lower their chances of getting heart disease. Read about how the members of the Ramírez family react to the news about their risks for heart disease. Then place an X next to the name of the family member with whom you identify the most.

  • Mariano: “I don't really care.”
    Mariano learns that he is at risk for heart disease, but he is not concerned about it. He gets upset when reminded about changing his unhealthy habits. He has no intention of making changes for better health. “Whatever will be, will be,” claims Mariano
  • Carmencita: “I need to make changes, but I can't get started.”
    Carmencita is worried and depressed, because she is aware of her chances of getting heart disease. She thinks about making changes, but cannot get started. She feels trapped and is not motivated to take steps for better health. “You can bring a horse to water, but you can't make it drink,” ponders Carmencita.
  • Virginia: “I am making plans.”
    Virginia learns that she is at risk for heart disease and thinks that she should get ready to make changes. Instead of just saying, “I will start to make changes tomorrow,” she talks to her friends about the plan she has in mind. “Walking the walk is harder than talking the talk,” thinks Virginia.
  • Doña Fela: “I am taking action.”
    Doña Fela learns that she is at risk for heart disease and quickly starts doing something about it. She goes to classes to learn how to improve her health. She practices what she learns. She feels confident and cheerful. Doña Fela makes simple changes and helps others to do the same. “An ounce of prevention is better than a pound of cure,” believes Doña Fela.
  • Néstor: “I stay on the healthy path.”
    Néstor is making changes and is motivated to stay on track to improve his health. He knows that it is easy to fall back into old habits. He makes plans to prevent setbacks and learns to start again if he needs to. He is positive toward life. He asks for help and does not give up. “Time is gold, and health is priceless,” says Néstor.

Please answer these questions after completing all of the sessions of the “Your Heart, Your Life” manual.  Mark your answer with an X.

  1. How satisfied are you with the Your Heart, Your Life sessions presented by promotores? I am not satisfied, I am somewhat satisfied, I am satisfied, I am very satisfied.
  2. With whom have you shared the information from the sessions? Mark your answer with an X. You may select more than one answer. Friends, Family, Coworkers, Other (please specify):

Back to Session 12

Information on this page is taken from the English print version of “Your Heart, Your Life, A Community Health Worker's Manual.” U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute, NIH Publication No. 08-3674, Originally Printed 1999, Revised May 2008.

Last Updated March 2012

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