NJPN s WISE Program Questionnaire Rev 10/13 Page 1

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1 Thank you for participating in the WISE program over the last six weeks. Please complete the following questionnaire. Keep in mind there are no wrong answers. We are simply looking for your thoughts and impressions. Your honesty and candidness will help us better understand how our program impacts seniors and will help us to improve our program and serve even more seniors in the future. NJPN s WISE Program Questionnaire Rev 10/13 Page 1

2 Section I. Please indicate how frequently you engage in the following behaviors AFTER participating in the Wise Program. 1 I am involved in decisions about my health care. 2 I tell my doctor how I feel about different treatments. 3 I tell my doctor if I have any problems doing a recommended treatment. 4 I ask my doctor about the kind of problems I might have doing a recommended treatment. 5 I ask my doctor enough questions to get the information I need to make my own decisions about which treatment to choose. 6 I tell my doctor my opinion about my care and treatment. 7 I am satisfied with the way I manage my own health care. 8 I talk to others about using alcohol safely. 9 I use alcohol safely. 10 I talk to others about using prescription medication safely. AFTER Participating in the WISE Program NJPN s WISE Program Questionnaire Rev 10/13 Page 2

3 AFTER Participating in the WISE Program 11 I use prescription medication safely. 12 I talk to others about using over-the-counter medication safely. 13 I use over-the-counter medication safely. 14 I tell my doctor about the over-the-counter medicines I use. 15 I read the instructions about over-the-counter medicines before using them. 16 I know how and where to dispose of prescription medications safely. 17 I talk to a healthcare provider or pharmacist about the over-the-counter medicines I use. 18 If my doctor did not tell me about my prescription medicine, I would ask about it. 19 I read the instructions about prescription medicines before using them. 20 I am familiar with the dangers of prescription drug abuse and know how to safely store them to prevent theft/abuse by others. NJPN s WISE Program Questionnaire Rev 10/13 Page 3

4 Section II. Please indicate how frequently you engaged in the following behaviors BEFORE participating in the Wise Program. 1 I was involved in decisions about my health care. 2 I told my doctor how I feel about different treatments. 3 I told my doctor if I have any problems doing a recommended treatment. 4 I asked my doctor about the kind of problems I might have doing a recommended treatment. 5 I asked my doctor enough questions to get the information I need to make my own decisions about which treatment to choose. 6 I told my doctor my opinion about my care and treatment. 7 I was satisfied with the way I manage my own health care. 8 I talked to others about using alcohol safely. 9 I used alcohol safely. 10 I talked to others about using prescription medication safely BEFORE Participating in the WISE Program NJPN s WISE Program Questionnaire Rev 10/13 Page 4

5 BEFORE Participating in the WISE Program 11 I used prescription medication safely. 12 I talked to others about using over-the-counter medication safely. 13 I used over-the-counter medication safely. 14 I told my doctor about the over-the-counter medicines I use. 15 I read the instructions about over-the-counter medicines before using them. 16 I know how and where to dispose of prescription medications safely. 17 I talked to a healthcare provider or pharmacist about the over-the-counter medicines I use. 18 If my doctor did not tell me about my prescription medicine, I asked about it. 19 I read the instructions about prescription medicines before using them. 20 I am familiar with the dangers of prescription drug abuse and know how to safely store them to prevent theft/abuse by others. NJPN s WISE Program Questionnaire Rev 10/13 Page 5

6 Section III. Please answer the following questions. 1. In the past six weeks, have you changed any behaviors to promote a healthier lifestyle? Yes No 2. Please indicate with a check mark whether you have made any of the following changes to promote a healthier lifestyle since participating in the WISE Program. Check all changes that apply. changed my doctor tried to take better care of myself in general asked my doctor questions asked my doctor to change a prescription or treatment asked my doctor to reduce my medication initiated a conversation with my doctor about my health brought a friend or family member with me when I visited a doctor told a doctor about the over-the-counter medication I take told a doctor about the supplements I take set a health goal for myself sought additional information about a health care topic spoken more openly to my doctor spoken more openly with close family members or friends about my health begun to exercise or increase the amount of exercise I get improved my diet reduced or eliminated my use of alcohol reduced or eliminated my use of tobacco products used a pill box to organize my medicines NJPN s WISE Program Questionnaire Rev 10/13

7 kept a list of all medications in my purse or wallet learned how to properly dispose of old/unwanted prescription and over-the counter medications safely in my community by visiting spoke to a friend about the dangers of prescription drug abuse and the importance of keeping prescription medications locked in a safe place at home spoken to a friend or counselor when I was feeling down enlisted others in healthy lifestyle activities shared information I learned through the WISE Program with someone else sought opportunities to learn new things (for example, take a class) other, please explain using the space below or on the back of this sheet: NJPN s WISE Program Questionnaire Rev 10/13