Chronic Pain Self-Management Program Pre-Survey

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Thank you for your participation in the Chronic Pain Self-Management Program brought to you by On Lok 30th Street Senior Center. This program is partially funded by the City of San Francisco Department of Disability and Aging Services (DAS). The data collected from this survey will be reported to DAS and kept strictly confidential. Once you complete this survey, you will be registered for the workshop.

Email *

Name

1. How old are you today?

2. Do you reside in San Francisco?

Yes

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2a. If you checked "No," please list what city:

3. Do you live alone?

Yes

Decline to state

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4. What is your gender? (Check one that best describes your current gender identity)

Male

Female

Trans Male

Trans Female

Genderqueer/Gender Non Binary

Not listed

Decline to state

Clear selection

5. How do you describe your sexual orientation?

Straight/Heterosexual

Bisexual

Gay/Lesbian/Same-Gender Loving

Questioning/Unsure

Not listed

Decline to state

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6. Are you of Hispanic, Latino, or Spanish origin?

Yes

Decline to state

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7. What is your race? Check all that apply.

American Indian or Alaska Native

Asian Indian

Black or African American

Cambodian

Chinese

Filipino

Guamanian

Hawaiian

Korean

Japanese

Laotian

Latino/Latina

Samoan

Vietnamese

White

Other Asian

Other Pacific Islander

Other race

Decline to state

8. Is your household annual income below the federal poverty line?

Yes

Decline to state

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9. Have you ever served in the United States military?

Yes

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10. Are you the spouse, legal partner, or child of a person who is serving in or who has served in the United States military?

Yes

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11. Have you ever been diagnosed with any of the following chronic conditions?

Yes

Alzheimer's Disease or other Dementia

Anxiety Disorder

Arthritis/Rheumatic Disease

Asthma/Emphysema/Other Breathing or Lung Problem

Cancer or Cancer Survivor

Chronic Pain

Depression

Diabetes (High Blood Sugar)

Heart Disease

High Cholesterol

Hypertension (High Blood Pressure)

Kidney disease

Obesity

Osteoporosis (Low Bone Density)

Post-Traumatic Stress Disorder

Stroke

Substance Use Disorder

Other Chronic Condition

Yes

Alzheimer's Disease or other Dementia

Anxiety Disorder

Arthritis/Rheumatic Disease

Asthma/Emphysema/Other Breathing or Lung Problem

Cancer or Cancer Survivor

Chronic Pain

Depression

Diabetes (High Blood Sugar)

Heart Disease

High Cholesterol

Hypertension (High Blood Pressure)

Kidney disease

Obesity

Osteoporosis (Low Bone Density)

Post-Traumatic Stress Disorder

Stroke

Substance Use Disorder

Other Chronic Condition

Clear selection

12. How confident are you that you can manage your chronic pain so you can do the things you need and want to do?

Not sure at all

Totally sure

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13. Where did you hear about our program?

Doctor or healthcare professional

Employer

Flyer or poster

Family member or friend

Pharmacist or pharmacy employee

Health insurance provider

Internet or website

Other:

14. Are you interested in any of our other programs? If so, which ones?

Chronic Disease Self-Management Program (Healthier Living)

Diabetes Education Empowerment Program

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