IMS 5-2-1-0 Health Care Survey
Thank you for your interest in becoming at 5-2-1-0 registered health care site. By completing this survey your clinic will be a 5-2-1-0 Health Care Registered Site. As a 5-2-1-0 Health Care Registered Site you are committing to working towards these 3 goals:

1. Connect to your community and the 5-2-1-0 community efforts by displaying 5-2-1-0 Healthy Choices Count posters in ALL waiting rooms and ALL exam rooms where patients are seen.
2. Accurately weigh and measure patients. ALL providers determine body mass index (BMI), BMI percentile, and weight classification for patients aged two years and older at well-child visits.
3. Have a respectful conversation around healthy eating and active living. ALL providers use the 5-2-1-0 Healthy Habits Questionnaire at well-child visits for patients

To maintain 5-2-1-0 Health Care Registered Site status you will be emailed this survey to complete annually in September. If your clinic accomplishes ALL 3 goals above, your clinic will be awarded 5-2-1-0 Health Care Site of Distinction status.

Applications will be reviewed at the beginning of each month, and from there you will receive a letter notifying you of your completed registration as well as next steps! You will also be provided a window cling to display identifying that your program participates in 5-2-1-0 Healthy Choices Count!

Email address *
Date *
MM
/
DD
/
YYYY
Name of Practice *
Your answer
Address of Practice *
Your answer
County of Practice *
Your answer
Your Full Name *
Your answer
What is your role in the practice? (please select one) *
What is the total number of clinicians in your practice who conduct well-child visits for patients ages 0-18 yrs? (include PA, NP, MD/DO) *
Your answer
What is the approximate number of active patients ages 0-18 yrs in your practice? *
Your answer
Is the 5-2-1-0 Health Care poster currently displayed in your practice waiting room? *
Is the 5-2-1-0 Health Care poster currently displayed in your practice exam rooms where patients are seen? *
How many posters would you need to display in all of your exam rooms and waiting rooms? *
Your answer
In the last 12 months, did at least one provider in your practice connect to your community in any of the following ways to support healthy eating and active living? Check all that apply. *
Required
In the past 12 months, did at least one provider in your practice advocate in any of the following ways to support healthy eating and active living? Check all that apply. *
Required
At well- child visits, how many providers in your practice routinely have Body Mass Index (BMI) percentile determined for their patients age two years and older *
At well-child visits, how many providers in your practice routinely have discussions with patients/families around the results of the patient’s BMI measurement? *
How many providers in your practice routinely use planned follow-up visits for children to further evaluate and provide more intensive treatment for patients with a BMI greater than the 85th percentile? (Based on the Pediatric Obesity Prevention and Treatment Algorithm Stage 1 and Stage 2.) *
Would you like to receive more information on planned follow-up visits? *
At well-child visits, how many providers in your practice routinely have weight for length measured for their patients younger than two years? *
At well-child visits, how many providers in your practice routinely have discussions with families around the result of the patient’s weight for length measurement? *
At well-child visits, how many providers in your practice routinely counsel on healthy eating and active living using the 5-2-1-0 Healthy Habits Questionnaire? *
What percentage of patients are you setting goals with related to healthy eating andphysical activity? *
How confident are you in talking about healthy eating and physical activity with your patients? *
Not at all confident
Very confiedent
Does your practice screen patients for food insecurity? *
Does your practice connect patients with local or statewide nutrition assistance programs? Please check all that apply. *
Required
At well-child visits, how many providers in your practice routinely have Body Mass Index (BMI) percentile determined for patients with intellectual or developmental disabilities? *
At well-child visits, how many providers in your practice routinely have discussions with patients/families around the result of the BMI measurement for their patients with intellectual or developmental disabilities? *
At well-child visits, how many providers in your practice routinely counsel their patients with intellectual or developmental disabilities on healthy eating and active living using the 5-2-1-0 Healthy Habits Questionnaire? *
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service