Steps to Better Health Questionnaire 1> QUESTIONS2> ABOUT YOU3> YOUR COPY Think about yourself in relation to the following areas that may affect your health and wellbeing. 1. My Connection with Family* 0Not at all connected 1 2 3 4 5 6 7 8 Very connected 2. My connections with people outside my family (such as friends, community groups, social clubs)* 0Not at all connected 1 2 3 4 5 6 7 8 Very connected 3. My employment, volunteering or retirement situation* 0Not at all satisfied 1 2 3 4 5 6 7 8 Very satisfied 4. My level of education and training* 0Not at all satisfied 1 2 3 4 5 6 7 8 Very satisfied 5. My financial situation* 0Very Worried 1 2 3 4 5 6 7 8 Not at all worried 6. My harmful habits or addictions (such as smoking, gambling, compulsive shopping, drugs/alcohol) *6. My harmful habits or addictions (such as smoking, gambling, compulsive shopping, drugs/alcohol) I don't have any 6. My harmful habits or addictions (such as smoking, gambling, compulsive shopping, drugs/alcohol)* 0Very concerned 1 2 3 4 5 6 7 8 Not at all concerned 7. My access to affordable, healthy food (such as fresh fruit, vegetables, meat)* 0Poor access 1 2 3 4 5 6 7 8 Easy access 8. My access to transport (public transport or your own transport)* 0Poor access 1 2 3 4 5 6 7 8 Easy access 9. My access to suitable housing or accommodation* 0Poor access 1 2 3 4 5 6 7 8 Easy access 10. My mental health* 0Very concerned 1 2 3 4 5 6 7 8 Not at all concerned 11. My physical health* 0Very concerned 1 2 3 4 5 6 7 8 Not at all concerned 12. My access to spaces for recreation (such as parks, ovals, playgrounds, beaches)* 0Poor access 1 2 3 4 5 6 7 8 Easy access 13. My support when I provide care to others (such as relative, partner, disabled child, or friend/neighbour) *13. My support when I provide care to others (such as relative, partner, disabled child, or friend/neighbour) I am not a carer 13. My support when I provide care to others (such as relative, partner, disabled child, or friend/neighbour)* 0Not supported 1 2 3 4 5 6 7 8 I have all the support I need 14. My safety at home* 0Very concerned 1 2 3 4 5 6 7 8 Not at all concerned 15. My safety in the community*How concerned are you about your safety where you live, work and/or in the community? 0Very concerned 1 2 3 4 5 6 7 8 Not at all concerned 16. My access to assistance with legal matters *16. My access to assistance with legal matters I don't know 16. My access to assistance with legal matters* 0Poor access 1 2 3 4 5 6 7 8 Easy access 17. My childhood was* 0Unhappy 1 2 3 4 5 6 7 8 Contented/happy 18. My access to health services when I need them (such as a doctor, hospital, psychologist or other health professional I might need)?* 0Poor access 1 2 3 4 5 6 7 8 Easy access 19. My access to other support services if/when I need them (such as home care, respite, disability support, parenting support, or other supports I might need)? *19. My access to other support services if/when I need them (such as home care, respite, disability support, parenting support, or other supports I might need)? I don't know 19. My access to other support services if/when I need them (such as home care, respite, disability support, parenting support, or other supports I might need)?* 0Poor access 1 2 3 4 5 6 7 8 Easy access This field is hidden when viewing the form20. Generally, how have you been coping during the COVID 19 pandemic?* 0Not at all well 1 2 3 4 5 6 7 8 Very well This field is hidden when viewing the form21. Mobility* I have no problems with walking around I have slight problems with walking around I have moderate problems with walking around I have severe problems with walking around I am unable to walk around This field is hidden when viewing the form22. Personal Care* I have no problems with washing or dressing myself I have slight problems with washing or dressing myself I have moderate problems with washing or dressing myself I have severe problems with washing or dressing myself I am unable to wash or dress myself This field is hidden when viewing the form23. Usual Activities (e.g. work, study, housework, family or leisure activities)* I have no problems doing my usual activities I have slight problems doing my usual activities I have moderate problems doing my usual activities I have severe problems doing my usual activities I am unable to do my usual activities This field is hidden when viewing the form24. Pain / Discomfort* I have no pain or discomfort I have slight pain or discomfort I have moderate pain or discomfort I have severe pain or discomfort I have extreme pain or discomfort This field is hidden when viewing the form25. Anxiety / Depression* I am not anxious or depressed I am slightly anxious or depressed I am moderately anxious or depressed I am severely anxious or depressed I am extremely anxious or depressed This field is hidden when viewing the form26. We would like to know how good or bad your health is TODAY. This scale is numbered from 0 to 100.*100 means the best health you can imagine 0 means the worst health you can imaginePlease enter a number from 0 to 100.27. Services and Supports You Have Used Please choose which, if any, of the following services, supports or activities you have accessed since January 2020. Choose as many that are applicable.This field is hidden when viewing the formSocial, Sport & Recreational Activities Board or committee member of a club or association Camping / caravanning / boating / fishing Church and/or church activities Dancing lessons Fitness Centre / Gym On-line gaming Hobby or social group or club Library Member of a Facebook or other social media group Men’s Shed Service Club eg Lions, Rotary, Country Women’s Association etc Social Group provided by an aged care provider eg Barossa Village, Tanunda Lutheran Care, Barossa Council Home Assist Sporting club Volunteering Wellbeing Centre None of these Other Social, Sport & Recreational Activities This field is hidden when viewing the formOtherThis field is hidden when viewing the formHealth & Medical Services and Supports Accident & Emergency department of a hospital Art Therapy; Music Therapy Audiology; Speech Pathology Chiropractor; Exercise Physiology; Occupational Therapy (OT); Physiotherapy Dentist Dietician Drug / Alcohol Rehabilitation Doctor / GP / After hours GP Mental Health Peer Support Group Psychiatrist Psychologist Social worker Specialist None of these Other Health & Medical Services & Supports This field is hidden when viewing the formOtherThis field is hidden when viewing the formOther Services & Supports Advocacy Services Aged Care Services Centrelink Community Transport (Barossa Council) Domestic Violence Support Emergency Food Relief Financial Counselling Homelessness Support Job Seeker Agency NDIS support coordination None of these Other This field is hidden when viewing the formOther MORE ABOUT YOU20. Your age*Please select your age18-2425-3031-3940-5455-6465-7475 and over21. Your gender* Male Female Other 22. Your postcode*Please select5118523553505351535253535355UnsureOtherOther postcode*This field is hidden when viewing the form31. What is the name of your town?23. Your current status* Employed Full Time Employed Part Time Employed Casually Self Employed Unemployed and seeking work Disability Support Pension Aged Pension Carer Pension Other OtherThis field is hidden when viewing the form33. Have you undertaken any volunteering activities in the past 12 months?* Yes No Unsure This field is hidden when viewing the form34. Are you a NDIS participant?* Yes No Unsure 24. Do you identify as an Aboriginal and/or Torres Strait Islander person?* Yes No Unsure 25. Where were you born?* Australia Overseas in an English speaking country Overseas in non-English speaking country Unsure 26. What is your marital status?* Married De facto relationship Separated/Divorced Widowed Never Married Rather not say 27. Household Type* Couple with Children Couple without Children One Parent Family Group Household Lone Person Other Other Household TypeThis field is hidden when viewing the form38. Which of the following best describes the highest qualification you have obtained?*Please select your highest qualificationStill at schoolLeft school at 15 or lessLeft school after age 15 but still studyingTrade qualification/apprenticeshipCertificate/Diploma – one year full time or lessCertificate/Diploma – more than one yearBachelor Degree or higherRather not sayThis field is hidden when viewing the form39. Before tax is taken out, which of the following best describes your household’s income, from all sources, over the last 12 months?*Please select your household incomeUnder $20,000$20,000 – $39,999$40,000 - $59,999$60,000 - $79,999$80,000 - $99,999$100,000 - $149,999$150,000 - $179,999$180,000 or morePrefer not to say YOUR ANSWERSDo you want to receive a copy of your answers as well as see them on the screen now? I would like to receive my answers via email* Yes No Email Address* People who score 4 or below on any of questions 1 – 19 often find it helpful to seek support. You will find many services and supports listed on the Barossa Cares website or you can choose to download a directory of supports and services by clicking here. If you are worried about any of your scores, it is recommended you talk to your doctor or other health professional about your concerns. If you are experiencing distress, you can access support by calling Lifeline on 12 11 14 any time of the day or night.This field is hidden when viewing the formI would like to receive a copy of suggested supports by email* Yes No This field is hidden when viewing the formEmail Address* I would like my health professional to receive a copy of my answers via email* Yes No Your Name*Health Professional's Email Address* FOLLOW UP SURVEYThis field is hidden when viewing the formWould you like to be involved in a follow up survey in 6 months to see how you are doing?* Yes No, please do not contact me again Maybe, contact me in 6 months and ask me. This field is hidden when viewing the formYour Name*This field is hidden when viewing the formYour Email addressThis field is hidden when viewing the formYour Phone number
