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pdfNDEP Diabetes HealthSense Participant Post Survey
The National Diabetes Education Program (NDEP) is trying to find out how well the Diabetes HealthSense website can help people at risk for diabetes and people
with diabetes. You will help improve Diabetes HealthSense by taking this survey. This survey will take you about 20 minutes to complete. The survey includes
questions about you and your health. Unless the directions say otherwise, please choose one response for each question. Your survey answers are private.
Public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and
maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for
reducing this burden, to: NIH, Project Clearance Branch, 6705 Rockledge Drive, MSC 7974, Bethesda, MD 208927974, ATTN: PRA (0925xxxx*). Do not return the completed form to this address.
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NDEP Diabetes HealthSense Participant Post Survey
ID Code
To keep your responses private an ID code will be created using the following information.
Please write down YOUR first and last initials:
[Example: If your name is Jane Smith choose “J” for your First name
initial and “S” for your Last name initial; If your name is Jane DoeSmith
choose “J” for your First name initial and “D” for your Last name initial]
First name initial
6
Last name initial
6
What is the MONTH and YEAR of your birth?
[Example: Choose May and 1995 if your birthday is May 22,
1995]
Birth Month
Birth date:
6
Birth Year
6
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NDEP Diabetes HealthSense Participant Post Survey
Please choose your program location:
j Site 1
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n
j Site 2
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j Site 3
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j Site 4
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j Site 5
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j Site 6
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j Site 7
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j Site 8
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j Site 9
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j Site 11
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j Site 12
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j Site 13
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j Site 10
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j Site 14
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j Site 15
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Page 3
NDEP Diabetes HealthSense Participant Post Survey
Resources
1. How often in the past month have you used the…
23 times this
Once this month
a. NDEP Diabetes HealthSense Website
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n
j
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j
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j
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b. Resources you found on the Diabetes HealthSense Website
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c. The American Diabetes Association Website (Diabetes.org)
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month
Once a week
More than once a
Never
week
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NDEP Diabetes HealthSense Participant Post Survey
Resources
2. How helpful do you think the following were?
Never used this
Not helpful at all
A little helpful
Helpful
Very helpful
a. Diabetes HealthSense Website
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n
j
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j
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j
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j
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b. Resources you found on the Diabetes HealthSense Website
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j
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j
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website
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NDEP Diabetes HealthSense Participant Post Survey
3. How would you describe your experience with these NDEP resources?
Never heard of it
Heard of it but do
not have it
Have it but have Have it and used it Have it and use it a
not used it
once
lot
a. Small Steps. Big Rewards: Your GAMEPLAN to Prevent Type 2 Diabetes
j
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n
j
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j
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j
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j
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b. Choose More than 50 Ways to Prevent Diabetes
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j
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j
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j
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c. Paso a Paso
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j
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d. Get Real! You Don't Have to Knock Yourself Out to Prevent Diabetes
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j
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NDEP Diabetes HealthSense Participant Post Survey
Resources
4. In the last month, have you participated in a diabetes education class or program? (For example, attended one or more
individual or group classes or meetings with a diabetes educator, nurse or dietitian?)
j No
k
l
m
n
j Yes
k
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m
n
If yes, please specify
5
6
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NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
5. Which of the following can quickly raise your blood glucose?
j Baked chicken
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n
j Swiss cheese
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n
j Baked potato
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n
j Peanut butter
k
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m
n
6. Eating foods lower in saturated and trans fat decreases your risk for:
j Nerve disease
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l
m
n
j Kidney disease
k
l
m
n
j Heart disease
k
l
m
n
j Eye disease
k
l
m
n
Page 8
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
7. The A1C is a measure of your average blood glucose for the past:
j Day
k
l
m
n
j Week
k
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n
j 23 months
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n
j 6 months
k
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8. Which should not be used to treat low blood glucose?
j 3 hard candies
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n
j 1/2 cup orange juice
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n
j 1 cup diet soft drink
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n
j 1 cup skim milk
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m
n
Page 9
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
9. Which of the following is the least amount of physical activity you should do to prevent or manage diabetes?
j 30 minutes of activity, five times a week (or 150 minutes per week)
k
l
m
n
j 10 minutes of activity, seven days a week (or 70 minutes per week)
k
l
m
n
j 45 minutes of activity, six days a week (or 270 minutes per week)
k
l
m
n
10. Which of the following exercise programs includes a mix of strength, flexibility and aerobic activities?
j Walking, running, and swimming
k
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m
n
j Lifting weights, pushups, situps
k
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m
n
j Walking, lifting weights, stretching
k
l
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n
j Stretching, deep breathing, meditating
k
l
m
n
Page 10
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
11. The best way to lose weight is to:
j Limit amount of physical activity
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l
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n
j Increase portion sizes
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n
j Combine healthy eating and exercise
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n
j Reduce dietary fat without reducing calories
k
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n
12. Which of the following factors contribute to a person’s weight? (Choose one or more)
c Family history and genetics
d
e
f
g
c Environment
d
e
f
g
c Metabolism
d
e
f
g
c Behavior or habits
d
e
f
g
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NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
13. The best way to take care of your feet is to:
j Check them each day for cuts, blisters and swelling
k
l
m
n
j Massage them with alcohol each day
k
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m
n
j Soak them for one hour each day
k
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n
j Buy shoes a size larger than usual
k
l
m
n
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NDEP Diabetes HealthSense Participant Post Survey
14. People with diabetes whose blood glucose is out of control are at greater risk of which complications? (Choose one or
more)
c Serious eye problems
d
e
f
g
c Circulation problems
d
e
f
g
c Kidney Problems
d
e
f
g
c Allergy problems
d
e
f
g
c Gum disease
d
e
f
g
c Heart attack or stroke
d
e
f
g
Page 13
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
15. Which of the following may be a sign of an emotional low and/or depression in a person with diabetes? (Choose one or
more)
c Sleeps most of the day
d
e
f
g
c Does not have an interest or find pleasure in activities
d
e
f
g
c Does not feel in control of their diabetes
d
e
f
g
c Discusses diabetes care with family and friends
d
e
f
g
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NDEP Diabetes HealthSense Participant Post Survey
16. Depression can raise your blood glucose by causing you to eat too much, do too little, and reduce your motivation to
take care of yourself.
j True
k
l
m
n
j False
k
l
m
n
17. Which of the following steps are important ways to help you achieve your goals? (Choose one or more.)
c Making a plan with realistic goals
d
e
f
g
c Tracking progress
d
e
f
g
c Avoiding rewards
d
e
f
g
c Using a support system
d
e
f
g
Page 15
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
18. For each statement, please check the option that best describes your behaviors.
Have you:
No, and I do not
plan to
No, but I plan to
No, but I plan to
Yes, I started this
within the next 6
within the next
less than 6 months
Yes, I have been
doing this for 6
months
month
ago
months or longer
a. Looked for resources to help you learn about or manage your diabetes?
j
k
l
m
n
j
k
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m
n
j
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m
n
j
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m
n
j
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n
b. Set a healthy eating or weight loss goal?
j
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m
n
j
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n
j
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n
j
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n
j
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n
c. Reduced the amount of fat in your diet?
j
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m
n
j
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m
n
j
k
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n
j
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m
n
j
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n
d. Reduced the number of calories you eat?
j
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m
n
j
k
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m
n
j
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m
n
j
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n
j
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n
e. Kept track of what you eat and drink most days?
j
k
l
m
n
j
k
l
m
n
j
k
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m
n
j
k
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m
n
j
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n
f. Set a physical activity goal?
j
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m
n
j
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n
j
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n
j
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n
j
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n
g. Fit exercise into your daily routine (for example, took the stairs instead of elevator, etc)?
j
k
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m
n
j
k
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n
j
k
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m
n
j
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n
j
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n
h. Exercised for 30 minutes at least 5 days a week?
j
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n
j
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n
j
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n
j
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n
j
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n
i. Kept track of your physical activity most days of the week?
j
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m
n
j
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n
j
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n
j
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n
j
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Page 16
NDEP Diabetes HealthSense Participant Post Survey
Knowledge and Behaviors
19. Are you seriously thinking of quitting smoking?
j I have never smoked or I quit more than 6 months ago
k
l
m
n
j I am not thinking of quitting
k
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n
j I plan to quit within the next 6 months
k
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n
j I plan to quit within the next 30 days
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n
j I quit within the last 6 months
k
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n
Page 17
NDEP Diabetes HealthSense Participant Post Survey
Please indicate the degree to which each of the following items may be bothering you. If you feel that a particular item is not a bother or a problem for you, you
would check “1.” If it is very bothersome to you, you might check “6.”
20. How much do the following feelings bother you in your life?
1 Not a
problem
2
3
4
5
6 Serious
problem
a. Feeling overwhelmed by the demands of living with diabetes or at risk of developing diabetes.
j
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m
n
j
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n
j
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n
j
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n
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j
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n
b. Feeling that you are often failing with your diabetes or diabetes prevention regimen.
j
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n
j
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n
j
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n
j
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j
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j
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NDEP Diabetes HealthSense Participant Post Survey
21. How confident do you feel that you can…
1 Not at all
confident
2
3
4
5
6 Totally
confident
a. Find resources to help you learn about or manage your diabetes or your risk for diabetes?
j
k
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m
n
j
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n
j
k
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n
j
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n
j
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n
j
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n
b. Set a healthy eating or weight loss goal?
j
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m
n
j
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n
j
k
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m
n
j
k
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m
n
j
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m
n
j
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n
c. Reduce the amount of fat in your diet?
j
k
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m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
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m
n
j
k
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m
n
d. Reduce the number of calories you eat?
j
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m
n
j
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n
j
k
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m
n
j
k
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m
n
j
k
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n
j
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n
e. Keep track of what you eat and drink most days of the week?
j
k
l
m
n
j
k
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m
n
j
k
l
m
n
j
k
l
m
n
j
k
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n
j
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n
f. Set a physical activity goal?
j
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m
n
j
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n
j
k
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n
j
k
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m
n
j
k
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n
j
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n
g. Fit exercise into your daily routine (for example, take the stairs instead of elevator, etc)?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
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m
n
j
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n
j
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n
h. Exercise for 30 minutes at least 5 days a week?
j
k
l
m
n
j
k
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n
j
k
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n
j
k
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n
j
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n
j
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n
i. Keep track of your physical activity most days of the week?
j
k
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m
n
j
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n
j
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n
j
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n
j
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j
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Page 19
NDEP Diabetes HealthSense Participant Post Survey
22. How confident do you feel that you can follow your health care provider’s recommendations for…
1 Not at all
confident
2
3
4
5
6 Totally
Does not
Confident
apply
a. Checking your blood glucose.
j
k
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m
n
j
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n
j
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n
j
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n
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n
b. Taking medications for diabetes, blood pressure, cholesterol, or heart disease?
j
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n
j
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n
j
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j
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j
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j
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j
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n
c. Checking your blood pressure?
j
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n
j
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n
j
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n
j
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n
j
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n
j
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j
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n
d. Checking your feet for redness or sores?
j
k
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m
n
j
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n
j
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n
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Page 20
NDEP Diabetes HealthSense Participant Post Survey
23. Think back over the past month. How often did you…
Never
Rarely
Sometimes
Often
All of the time
a. Fill half of your plate with fruits and vegetables at each meal?
j
k
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m
n
j
k
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m
n
j
k
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n
j
k
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m
n
j
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n
b. Reduce the amount of fat in your diet?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
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m
n
c. Reduce the number of calories you eat?
j
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m
n
j
k
l
m
n
j
k
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m
n
j
k
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n
j
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n
d. Reduce the number of unhealthy snacks and desserts/sweets you eat?
j
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n
j
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n
j
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n
j
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n
j
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n
e. Reduce your portion sizes?
j
k
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m
n
j
k
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m
n
j
k
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m
n
j
k
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n
j
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n
f. Choose drinks without added sugar like diet sodas and unsweetened tea?
j
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n
j
k
l
m
n
j
k
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n
j
k
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n
j
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n
g. Follow your diet goals and plans?
j
k
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m
n
j
k
l
m
n
j
k
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n
j
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n
j
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n
h. Track your food plan to measure progress?
j
k
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m
n
j
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n
j
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Page 21
NDEP Diabetes HealthSense Participant Post Survey
24. Think back over the past month. How often did you…
Never
Rarely
Sometimes
Often
All of the time
a. Exercise for 30 minutes at least 5 days a week?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
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m
n
b. Fit exercise into your daily routine (for example, take stairs instead of elevator, etc)?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
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n
c. Do different types of exercises such as stretching, strength training, walking?
j
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m
n
j
k
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m
n
j
k
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n
j
k
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n
j
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n
d. Follow your exercise goals and plans?
j
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m
n
j
k
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n
j
k
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n
j
k
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n
j
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e. Track your exercise to measure progress?
j
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n
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n
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Page 22
NDEP Diabetes HealthSense Participant Post Survey
25. Think back over the past month. How often did you do the following to cope with stress and emotions?
Never
Rarely
Sometimes
Often
a. Exercise?
j
k
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m
n
j
k
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m
n
j
k
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n
j
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n
b.Use relaxation techniques such as meditation or deep breathing?
j
k
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m
n
j
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n
j
k
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n
j
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n
c. Participate in a support group?
j
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m
n
j
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n
j
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n
j
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n
d. Use the support of family and friends?
j
k
l
m
n
j
k
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n
j
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n
j
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e. Participate in enjoyable hobbies?
j
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m
n
j
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n
j
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n
j
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n
f. Participate in faithbased activities?
j
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n
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n
j
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n
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Page 23
NDEP Diabetes HealthSense Participant Post Survey
26. Think back over the past month. How often did you follow your health care provider’s recommendations for…
Never
Rarely
Sometimes
Often
a. Checking your blood glucose.
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
All of the time Does not apply
j
k
l
m
n
j
k
l
m
n
b. Taking medications for diabetes, blood pressure, cholesterol, or heart disease?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
c. Checking your blood pressure?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
d. Checking your feet for redness or sores?
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
j
k
l
m
n
Page 24
NDEP Diabetes HealthSense Participant Post Survey
Thank you for completing our survey.
Page 25
| File Type | application/pdf |
| File Modified | 2014-01-07 |
| File Created | 2013-12-19 |