SPECIAL OLYMPICS PROJECT

Demographic Questions

1. Athlete’s First Name (first):

2. Athlete’s Surname (first):

3. Please choose an age group.

4. What community do you live closest to:

5. Who is answering this survey?

Athete Parent/caregiver Other

Lifestyle & Programming Questions

6. Considering your health experience indicate which of the following options are true for you?

Check the box beside the condition(s) you currently experience:

	It costs too much to eat healthy
	It's difficult to get transportation so I can go to programs or activities.
	I haven't found a healthcare professional I can trust trust.
	Communicating with healthcare professional.
	Finding a support group to help me with my goals has been hard
	I'm happy with my health experience

6b. Other:

7. Check the 3 most important things that you would change in your lifestyle to be healthier

Eat better foods so that I can lower the amount of sugar that I eat

Learn how to cook meals and prepare healthier snacks

Spend more recreation time with friends

Attend a regular fitness program

Nothing I like what I am doing

7b. Other:

8. Do you currently participate in Special Olympics PEI Wellness Programs?

Yes- Synergy, Crossfit_782, TCAP Fitness, Open Swims, or Community Walking Tracks
No- But I participate in a health and wellness program on my own
No- but I would like to start going to one

9. What programs would you like to attend in your community if they were available:

Cooking classes

Daily physical activiy

Learn how to ride a bike

Walking programs for me and my Special Olympic friends

Walking programs in my community to meet new people

9b. Other:

10. Check the following activities you would do if they were available:

Track your daily health and fitness activities

Watch a workout video

Watch a cooking video

Get ideas about cooking and what to eat

Get a list of healthcare workers that want to help me and my friends

Get information about caring for my personal health

Chat with a person about my health care

Watch a video about people's health stories

11. Would you participate in a monthly health and wellness workshop if it was offered in your area?

YES NO Maybe

12. Have you heard about the Special Olympics PEI Healthy Communities project?

YES NO Maybe

Healthy Athlete Screening & Healthcare Professionals

Special Smiles

13. Do you have a dentist that you see regularly?

YES NO

13a. If you answered yes, How often do you visit the dental clinic?

13b. When did you last get your teeth checked?

13c. What is the name of your dentist?

13d. If you answered no, please check which reasons fit best.

I am scared to go to the dental clinic.

I can't find one that I am comfortable with

I find one only when my teeth are sore.

There isn't a clinic close to where I live.

13i. Other:

Fit Feet

14 Do you have a Podiatrist (Foot Specialist) you see regularly?

YES NO

14a. If you answered yes, How often do you visit the podiatrist?

14b. When did you last get your feet checked?

14c. What is the name of your podiatrist?

14d. If you answered no, please check which reasons fit best.

I don’t think I need one .

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

There isn't a clinic close to where I live.

I don’t have the money to pay for a visit

I would like to see one if it was made available

14k. Other:

Healthy Hearing

15. Have you ever been to an Audiologist for your hearing?

YES NO

15a. If you answered yes, How often do you visit the Audiologist?

15b. When did you last get your hearing checked?

15c. What is the name of your Audiologist?

15d. If you answered no, please check which reasons fit best.

I don’t think I need one, I can hear fine.

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

There isn't a clinic close to where I live.

I don’t have the money to pay for a visit

I would like to see one if it was made available

15k. Other:

Opening Eyes

16. Do you have an Optometrist (Eye Doctor) you see regularly?

YES NO

16a. If you answered yes, How often do you visit the Optometrist?

16b. When did you last get your vision checked?

16c. What is the name of your Optometrist?

16d. If you answered no, please check which reasons fit best.

I don’t think I need one, I can see fine.

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

There isn't a clinic close to where I live.

I don’t have the money to pay for a visit

I would like to see one if it was made available

16k. Other:

MedFest

17. Do you have a Doctor you see regularly?

YES NO

17a. If you answered yes, How often do you visit the Doctor?

17b. When did you last get a medical check-up?

17c. What is the name of your Doctor?

17d. If you answered no, please check which reasons fit best.

I don’t think I need one.

I can't find one that I am comfortable with

I'm on the waitlist

There isn't a clinic close to where I live.

I would like to see one if it was made available

17j. Other:

Health Promotion

18. Have you ever been to a Dietitian for meal planning?

YES NO

18a. If you answered yes, How often do you visit the Dietitian?

18b. When did you last visit the Dietitian?

18c. What is the name of your Dietitian?

18d. If you answered no, please check which reasons fit best.

I don’t think I need one.

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

I don't know what they do.

I don’t have the money to pay for a visit

I would like to see one if it was made available

18k. Other:

Strong Minds

19. Do you see a Psychologist or Mental Health trainer often?

YES NO

19a. If you answered yes, How often do you visit a Psychologist or Mental Health trainer?

19b. When did you last see them?

19c. What is the name of your Psychologist or Mental Health trainer?

19d. If you answered no, please check which reasons fit best.

I don’t think I need one.

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

There isn't a clinic close to where I live.

I don’t have the money to pay for a visit

I would like to see one if it was made available

19k. Other:

Fun Fitness

20. Do you have a Physiotherapist or Occupation Therapist (Body/Joint/Movement Specialist) you see regularly?

YES NO

20a. If you answered yes, How often do you visit a Physiotherapist or Occupation Therapist?

20b. When did you last see them?

20c. What is the name of your Physiotherapist or Occupation Therapist?

20d. If you answered no, please check which reasons fit best.

I don’t think I need one.

I can't find one that I am comfortable with

I didn’t know there is someone in PEI .

There isn't a clinic close to where I live.

I don’t have the money to pay for a visit

I would like to see one if it was made available

20k. Other:

Thank you for completing this survey!

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