Health Literacy Universal Precautions Toolkit, 2nd Edition

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Insert Practice Name

Date: ________________________________

Instructions: 

Please answer the questions below about the care provided by this practice. Your answers will help us learn how well people in your provider’s practice explain things to you and make it easy for you to take care of your health.

First, we would like to know how well the clinicians and other staff in this practice explain things to you and how well they listen to you.

1. In the last 6 months, how often did people in this practice explain things in a way that was easy to understand?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

2. In the last 6 months, how often did people in this practice use medical words that you did not understand?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

3. In the last 6 months, how often did people in this practice talk too fast when talking with you?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

4. In the last 6 months, how often did anyone in this practice use pictures, drawings, models, or videos to explain things to you?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

5. In the last 6 months, how often did people in this practice listen carefully to you?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

6. In the last 6 months, how often did people in this practice interrupt you when you were talking?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

7. In the last 6 months, how often did people in this practice show interest in your questions and concerns?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

8. In the last 6 months, how often did people in this practice encourage you to ask questions?
    ___  Never.
    ___  Sometimes.
    ___  Usually.
    ___  Always.

9. In the last 6 months, did you see anyone in this practice for a specific illness or for any health condition?
    ___  Yes.
    ___  No. → go to question 13.

10. In the last 6 months, did anyone in this practice give you spoken instructions about what to do to take care of this illness or health condition?
     ___  Yes.
     ___  No. → go to question 13.

11. In the last 6 months, how often were these verbal instructions easy to understand?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

12. In the last 6 months, how often did anyone in this practice ask you to describe how you were going to follow these instructions?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

13. In the last 6 months, how often did people in this practice spend enough time with you?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

Now we would like to know how well clinicians and other staff in this practice have done in talking with you about any medicines that you take.

14. In the last 6 months, did you take any medicines that were recommended by someone in this practice?
     ___  Yes.
     ___  No. → go to question 23.

15. In the last 6 months, did anyone in this practice explain the purpose for taking each medicine?
     ___  Yes.
     ___  No. → go to question 17.

16. How often was the explanation easy to understand?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

17. In the last 6 months, did anyone in this practice explain how much to take of each medicine and when to take it?
     ___  Yes.
     ___  No. → go to question 20.

18. How often was the explanation easy to understand?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

19. In the last 6 months, how often did anyone in this practice suggest ways to help you remember to take your medicines?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

20. In the last 6 months, did anyone from this practice ask you to bring in all the prescription and over-the-counter medicines you were taking?
     ___  Yes.
     ___  No.

21. In the last 6 months, did you bring to this practice all the prescription and over-the-counter medicines you were taking?
     ___  Yes, I brought all of them.
     ___  No, I brought only some of them.
     ___  No, I didn’t bring any. → go to question 23.

22. In the last 6 months, did anyone in this practice look at your medicine bottles and talk with you about each medicine?
     ___  Yes.
     ___  No.

Now, we would like to know whether your clinician or other staff in this practice has given you written information about your health.

23. In the last 6 months, did anyone in this practice give you written information about how to take care of your health?
     ___  Yes.
     ___  No. → go to question 25.

24. In the last 6 months, how often did anyone in this practice explain or walk you through the written information that you were given?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

25. In the last 6 months, did you have to sign any forms at this practice?
     ___  Yes.
     ___  No. → go to question 27.

26. In the last 6 months, how often did someone explain the purpose of a form before you signed it?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

27. In the last 6 months, did you fill out any forms at this practice?
     ___  Yes.
     ___  No. → go to question 30.

28. In the last 6 months, how often were you offered help in filling out a form at this practice?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

29. In the last 6 months, how often were the forms that you got at this practice easy to fill out?
     ___  Never.
     ___  Sometimes.
     ___  Usually.
     ___  Always.

Now, we want to know whether your clinician and other staff in this practice have talked with you about classes or other services in the community that might be helpful for you.

30. In the last 6 months, did anyone in this practice ask if you ever have trouble paying for your medicines?
     ___  Yes.
     ___  No. → go to question 32.

31. In the last 6 months, did anyone in this practice assist you to get help for paying for your medicines?
     ___  Yes.
     ___  No.

32. In the last 6 months, did anyone in this practice talk to you about what was available in your community to help you with things like food, jobs, or housing?
     ___  Yes.
     ___  No.

33. In the last 6 months, did anyone in this practice ask if you want to improve your reading, writing, or math skills?
     ___  Yes.
     ___  No.

34. In the last 6 months, did anyone in this practice help you get services to improve your reading, writing, or math skills?
     ___  Yes.
     ___  No.

35. In the last 6 months, were you referred to another doctor, lab, or other facility?
     ___  Yes.
     ___  No. → go to question 37.

36. In the last 6 months, were you asked if you would like help making an appointment with the other doctor, lab, or other facility?
     ___  Yes.
     ___  No.

Now, we have some questions about you.

37. What is your age?
     ___  18 to 24.
     ___  25 to 34.
     ___  35 to 44.
     ___  45 to 54.
     ___  55 to 64.
     ___  65 to 74.
     ___  75 or older.

38. Are you male or female?
     ___  Male.
     ___  Female.

39. What is the highest grade or level of school that you have completed?
     ___  8th grade or less.
     ___  Some high school, but did not graduate.
     ___  High school graduate or GED.
     ___  Some college or 2-year degree.
     ___  4-year college graduate.
     ___  More than 4-year college degree.

40. Are you of Hispanic or Latino origin or descent?
     ___  Yes, Hispanic or Latino.
     ___  No, not Hispanic or Latino.

41. What is your race? Please mark one or more?
     ___  White.
     ___  Black or African American.
     ___  Asian.
     ___  Native Hawaiian or Other Pacific Islander.
     ___  American Indian or Alaskan Native.
     ___  Other.

42. How well do you speak English?
     ___  Very well.
     ___  Well.
     ___  Not well.
     ___  Not at all.

Thank you for taking the time to complete this survey!

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