Topic: Individual Assessment

Resources

Materials By Type

•	Assessment Materials, Forms & Instruments
•	Patient Education Materials
•	Program Management & Implementation
•	Spanish Materials
•	Staff Training Materials & Methods
•	Template Recruitment & Marketing Materials

Materials By Topic

•	Community Health Workers
•	General Administration
•	Goal Setting
•	Healthy Coping
•	Healthy Eating
•	Individual Assessment
•	Linking to Quality Clinical Care
•	Multiple Self Management Behaviors
•	Partnership Models for Self Management
•	Physical Activity
•	Smoking Cessation
•	Social Support
•	Systems to Support Organizational Capacity for Self Management

Resources
Individual Assessment

This section includes individual assessment materials related to various topics including goal setting, depression, action planning and more. It also includes provider documentation forms for individual patients or program participants. Materials are organized by the nature of their use.

Assessment Materials, Forms & Instruments

Action Plan Card English (Galveston County Health District)

Action Plan Card Spanish (Galveston County Health District)

Action Plan Form English (Galveston County Health District)

Action Plan Form Spanish (Galveston County Health District)

Attitudes Survey (Montana-Wyoming Tribal Leaders Council)

Behavior Worksheet (Galveston County Health District)

Case Management Intake Form (Minneapolis American Indian Center)
Diabetes Clinical Form (Minneapolis American Indian Center)
Diabetes Group Visit Form (St. Peter Family Medicine Residency)

Diabetes Patient Survey (St. Peter Family Medicine Residency)
Diabetes Provider Visit Form (St. Peter Family Medicine Residency)
Diabetes Support Group/ Self Management Class Feedback Form (Center for African American Health)

Goal Follow up Form (Galveston County Health District)
Goal Setting Assessment Tool (Richland County Health Department)
Goal Setting Form and Tips English/Spanish (Gateway Community Health Center)

Goal Setting Support Tool (Richland County Health Department)

Low Literacy Patient Assessment Tool 1 I 2 (Open Door Health Center)
Lifestyle Survey (Minneapolis American Indian Center)

Nutrition Assessment (Open Door Health Center)

Nutrition Goal Setting Form (Minneapolis American Indian Center)
Participant Registration Form (Gateway Community Health Center)
Participant Registration Form Spanish (Gateway Community Health Center)

Patient Assessment Form (Dept. of Family and Comm. Health/Marshall University)
Patient Assessment Form (Gateway Community Health Center)
Patient Assessment Form Spanish (Gateway Community Health Center)
Patient Diabetes Knowledge Questionnaire English (Gateway Community Health Center)
Patient Diabetes Knowledge Questionnaire Spanish (Gateway Community Health Center)
Patient Information Sheet English/Spanish (Open Door Health Center)

Program Evaluation (Galveston County Health District)

Program Intake Form (Campesinos Sin Fronteras)

Program Intake Form (Galveston County Health District)

Project Participant Post-test (Center for African American Health)

Project Participant Post-test (Richland County Department of Health)

Project Participant Pre-test (Center for African American Health)

Project Participant Questionnaire (Richland County Department of Health)
Questions for People with Diabetes (Galveston County Health District)
Self Efficacy Assessment Tool (La Clinica de La Raza)

Self Management Goal Form (Galveston County Health District)

Weekly Action Plan Form (Richland County Health Department)

Last update: 10/16/07