For MOVE!® program to be tailored to your
needs, your VA healthcare team needs you to complete a questionnaire.
This questionnaire is called the MOVE!11, because
it has 11 questions. The questions ask you about your medical history, what you
eat, how active you are and things that may be getting in the way of your being
able to manage your weight.
Once you complete the MOVE!11 questionnaire, you
will have the option to print a patient report. The report has a code at the
top of the first page. Bring the printed patient report or the code to your
appointment with your VA healthcare team. This code allows your VA healthcare
team to have access to your answers to the MOVE!11.
Click here to begin the MOVE!11 questionnaire.
The Paperwork Reduction Act of 1995 requires us to notify you that this
information collection is in accordance with the clearance requirements of
section 3507 of the Paperwork Reduction Act of 1995. As this information is
collected to facilitate the healthcare of veterans, this questionnaire is not
required to have an Office of Management and Budget (OMB) number. We anticipate
that the time needed to complete the questionnaire will average eleven (11)
minutes, including reading the instructions. This collection of information is
intended to fulfill the need identified by the Department of Veterans Affairs
(VA) to assist you in identifying your personal stumbling blocks for managing
your weight and collecting other information critical to assisting you with
managing your weight. Results will be used to automatically produce a report
which summarizes your weight management profile and points you to materials
that can address your individual needs. This information is stored in an
anonymous format. Veterans: if you are enrolled in VA healthcare, you can share
this information with your healthcare team by printing the report and bringing
the report to your next Primary Care appointment. The report contains a
retrieval number which will allow you to make the report a part of your VA
medical record. Use of this questionnaire is voluntary and failure to
participate will have no adverse effect on benefits to which you might
otherwise be entitled.
Privacy Act Information: VA is asking you to provide the information on
the questionnaire under 38 U.S.C. Sections 523, 527, 1701, 7318 in order for VA to
assist you with weight management. You will not be asked to identify yourself,
but you will be asked health information relevant to weight management. VA may
disclose the information you provide in answering the questions as permitted by
law. VA may make a "routine use" disclosure of the information as outlined in
the Privacy Act systems of records notices and in accordance with VHA Notice
of Privacy Practices. As detailed above, veterans have the voluntary option of
sharing this information with their VA healthcare team through the sharing of a