Outcomes Study Form

CME INFORMATION FOR:

____________________________________________

CMEs are given in cooperation with The Scottsdale Institute for Health and Medicine.

This activity is sponsored by:
The University of Arizona College of Medicine
at the Arizona Health Sciences Center

Outcomes Study

In an effort to continuously improve CME programming, please provide an assessment of any differences or changes you have noticed since your participation in this course.

Class Date:______________________________ Class Number:____________

Name:__________________________________

Please circle the answer most applicable :

1. How is your activity level now compared to before taking the course?

0 not applicable; activity was never a problem
1 much less active
2 somewhat less active
3 no change
4 somewhat more active; doing new things
5 much more active; great improvement in capacity to do things

2. How is your attendance record at work (school) now compared to before taking the course?

0 not applicable; activity was never a problem
1 much less active
2 somewhat less active
3 no change
4 somewhat more active; doing new things
5 much more active; great improvement in capacity to do things

3. How is your energy level and stamina overall now as compared to before taking the course?

0 was never a problem
1 much worse; much less stamina
2 somewhat worse, somewhat less stamina
3 no change
4 somewhat better
5 much more active; great improvement in capacity to do things

4. Overall, how do you feel now compared to before taking the course?

0 never a problem
1 much worse than before
2 somewhat worse
3 no change
4 somewhat better
5 much better; great improvement

5. Overall, how are your relationships compared to before taking the course?

0 relationships were not a problem
1 much worse than before
2 somewhat worse
3 no change
4 somewhat better
5 much better; great improvement

6. Overall, how do you cope with the stresses in your life now compared to before taking the course?

0 coping was not a problem
1 much worse than before
2 somewhat worse
3 no change
4 somewhat better
5 much better; great improvement

7. How is your blood pressure now (if you know) compared to before taking the course?

0 high blood pressure was not a problem to begin with
00 do not know
1 much higher; taking stronger drugs
2 somewhat higher
3 no change
4 improved; somewhat lower
5 much lower; greatly improved; reduced medication

8. Do you feel you got something of lasting value or importance from taking the course?

a. If you answered yes to the above question, please rate how important the course has been for you. Where 1 means least important and 5 means very important on the scale below.

1 2 3 4 5

b. If you answered yes to the above questions, please state what you feel you received from the course? This is your opportunity to provide positive feedback. Please use the back of the form if you need more room.

9. Do you use awareness of breath in your daily life?
____ often
____ sometimes
____ rarely
____ never

10. How useful do you feel awareness of breathing is helping you in coping successfully with stressful situations in your life?
____ very useful
____ somewhat useful
____ not very useful
____ of no use

11. Have you made any changes in your lifestyle as a result of taking the course?
Yes____ No____

12. As a result of greater awareness development through mindfulness practice has your relationship to your thoughts, feelings, and body sensations changed?
Yes____ No____
If yes, please state how?

13. Please rate how much change, if any, has occurred in your attitudes and behaviors as a result of your participation in the Stress Reduction Program. Put a number form 1 to 5 beside each item:
1 much worse
2 worse
3 unchanged
4 somewhat better; definitely improved
5 much better; great improvement

a. knowing how to take better care of myself ____
b. actually taking better care of myself ____
c. believing that I can improve my health ____
d. feeling self-confident ____
e. feeling hopeful ____
f. feeling assertive and able to express my needs and
feelings directly in my relationships ____
g. awareness of what is stressful in my life ____
h. awareness of stressful situations at the time they are
happening ____
i. ability to handle stressful situations appropriately ____
j. correcting negative health habits and self-destructive
behaviors ____