Core Connections Network Pre-Survey (2022)

Thank you for participating in the Houston Food Bank Core Connections Network program! During the CCN program, you will be empowered with knowledge and skills to actively manage your chronic condition while receiving healthy groceries at no cost to you through HFB’s Food Rx program. Participants are able to receive groceries at Food for Change Markets by agreeing to CCN eligibility requirements.

Information from the intake form, pre and post surveys, health outcome measures, data about program enrollment, program completion, and redemption of food will be collected, stored, and analyzed to understand the impact of Core Connections Network, and to make improvements to the program. The information you give us is considered confidential and we put several steps in place, including secure passwords and HIPAA privacy guidelines, to protect your information.

The information you provide will be used to track how much progress you have made throughout the duration of the CCN program. All information collected will only be shared with the CCN host organization/clinic and the Houston Food Bank. No data collected will be shared with any other organizations or agencies. Data collected will not have any impact on your completion of the program.

We look forward to having you as part of the CCN community!

Core Connections Network Program

Food for Change ID

Health Outcomes

Blood Pressure (for example - 120/60):

Medical History

The next set of items is about your experience with health care. Please select the answer that most closely reflects your experience.

3. Is there a place that you usually go when you are sick and need advice about your health?

YesNoI don't know

5. During the past 6 months, how many times have you seen a doctor or other healthcare professional about your health at a doctor’s office, a clinic or some other place? Do NOT include visits while in the hospital or the hospital emergency room.

6. In the past 6 months, how many times did you go to a hospital emergency room or Urgent Care center?

7. In the past 6 months, how many times did you stay in a hospital overnight or longer?

8. Do you ever have trouble paying for your medication?

YesNo

9. What type of insurance do you have?

Private Insurance (individual or group plans through an employer or Marketplace/Obamacare)Government Insurance (Military, TRICARE or VA)MedicareMedicaidI do not have insuranceOther

Please list below:

Health Status

The next set of items is about how you look after your own health. Please select the answer that most closely reflects your experience.

10. I monitor my condition(s) as recommended by my healthcare provider to the best of my ability.

11. I take my medication(s) as ordered by my healthcare provider to the best of my ability.

12. Would you say that in general your health is excellent, very good, good, fair, or poor? Health is the state of physical, social, and mental wellness.

14. How would you rate your ability to cope with other health problems that may occur in life (i.e., a cold, flu, fever, etc.)?

15. The questions in this scale ask you about your feelings and thoughts during the last month. In each case, please indicate your response by selecting the circle representing how often you felt or thought a certain way.

	All of the time	Most of the time	Some of the time	Not very often	Not at all
In the last month, how often have you felt that you were unable to control important things in your life?
In the last month, how often have you felt confident about your ability to handle your personal problems?
In the last month, how often have you felt that things were going your way?
In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?

Food Security

For the following section, please indicate how true each statement was for you/your household in the past 30 days.

16. The food that we bought just didn't last, and we didn't have money to get more. Was that often, sometimes, or never true for your household in the last 30 days?

Never trueSometimes trueOften trueDon't know/Prefer not to answer

17. We couldn't afford to eat balanced meals. Was that often, sometimes, or never true for your household in the last 30 days?

Never trueSometimes trueOften trueDon't know/Prefer not to answer

18. In the last 30 days, did you or other adults in your household ever cut the size of your meals or skip meals because there wasn't enough money for food?

YesNo Don't know/Prefer not to answer

19. In the last 30 days, how many days did this happen?

20. In the last 30 days, did you ever eat less than you felt you should because there wasn't enough money for food?

YesNo Don't know/Prefer not to answer

21. In the last 30 days, were you ever hungry but didn't eat because there wasn't enough money for food?

YesNoDon't know/Prefer not to answer

Habits & Behaviors

The next set of questions is about the fruits and vegetables you typically eat in a day and whether you were able to afford the food your households needs in the last 30 days.

22. How many servings of FRUIT do you usually eat or drink each day? Think of a serving as being about 1 medium piece, or 1/2 cup of fruit, or 3/4 cup of fruit juice. See chart below.

23. How many servings of VEGETABLES do you usually eat or drink each day? Think of a serving as being 1 cup of raw leafy vegetables, 1/2 cup of other cooked or raw vegetables, or 3/4 cup of vegetable juice. See chart below.

This section asks about your cooking skills and experience as well as how you feel about different aspects of your life:

24. How often have you done each of the following actions in the last month?

	All of the time	Most of the time	Some of the time	Not very often	Not at all
Plan meals ahead of time
Make a list before you go shopping
Plan meals to include at least 3 food groups
Think about healthy choices when deciding what to eat
Feel confident about managing money to buy healthy food
Use Nutrition Facts Label to make food choices
Cook meals at home using nutritious ingredients
Feel confident about cooking a variety of nutritious meals
Try a new recipe
Change recipes to make them more nutritious
Compare prices of foods to find the best prices of nutritious foods

25. For each question, please choose how confident you are in completing each task or statement:

	Not at all confident	Not very confident	Neutral	Fairly confident	Very confident
I can choose nutritious foods to eat when I am hungry
I can follow a diet that helps me manage my chronic condition
I can participate in physical activity
I can handle unplanned events that may pop up
I can remain calm when facing difficulties in my life
I can rely on my ability to cope in times of stress
When confronted with a problem, I can usually find possible solutions
I can find a way to compromise if someone disagrees with me
I can solve problems when there are barriers to managing my condition(s)
I can manage my condition(s)when they are out of control

Physical Activity

These last two items are about the activity you typically do in a month.

26. During the past month, other than your regular job, did you participate in any physical activity such as running, gardening, or walking?

YesNoDon't know/Not sure

27. How many times per week or per month did you take part in this activity during the past month? If you participated in this activity weekly, fill out option 1. If you participated monthly, fill out option 2. Option 1: Times per week

Option 2: Times per month

Contact Information

Allergies	Anemia
Anxiety	Asthma
Cancer (please specify)	Chronic Kidney Disease
Chronic Obstructive Lung Disease	Chronic Pain (please specify)
Depression	Diabetes
Gestational Diabetes	Heart Disease
High Blood Pressure	Pre Diabetic/Borderline Diabetes
Thyroid Disease	Other (please specify)