New Jersey Department of Health

Office of Minority and Multicultural Health

diabetes Self-Management Program

“TAKE CONTROL OF YOUR HEALTH”

POST-WORKSHOP PARTICIPANT SURVEY

ID Number:
Date:
Zip Code:

Monitoring Sugar Level
1.	Do you have a machine to test your blood sugar (glucose) level at home?	Yes No
2.	If yes, how many days in the last week did you test your blood sugar level? (If you were sick in the last week, think of the most recent 7 days when you were NOT sick).	________ days
3.	Do you know what the results mean?	Yes No
4.	Have you had a Hemoglobin A1c test in the past month?	Yes No

I. In general, would you say your health is: (check only one)
Excellent Very Good Good Fair Poor

II.	In the PAST WEEK, did you ever have any of the following symptoms: (Check only one)
1.	Increased thirst?	Yes No Don’t Know
2.	Dry mouth?	Yes No Don’t Know
3.	Decreased need for food?	Yes No Don’t Know
4.	Sickness in stomach or vomiting?	Yes No Don’t Know
5.	Belly pain?	Yes No Don’t Know
6.	Do you have to get up to urinate 3 or more times a night?	Yes No Don’t Know
7.	High blood sugar readings (300 mg or higher)?	Yes No Don’t Know
8.	Morning headaches?	Yes No Don’t Know
9.	Bad dreams?	Yes No Don’t Know
10.	Night sweats?	Yes No Don’t Know
11.	Lightheadedness or dizziness?	Yes No Don’t Know
12.	Shakiness or weakness?	Yes No Don’t Know
13.	Severe hunger?	Yes No Don’t Know
14.	Times when you fainted or passed out, even for a short time?	Yes No Don’t Know

III.	Daily Activities	(Circle one)
Not at all	Slightly	Moderately	Quite a bit	Almost totally
1.	During the past 2 weeks, how much has your sickness stopped you from being with family, friends, neighbors or groups?	0	1	2	3	4
2.	During the past 2 weeks, how much has your sickness stopped you from doing things you enjoy like reading, playing sports or other fun things?	0	1	2	3	4
3.	During the past 2 weeks, how much has your sickness stopped you from doing everyday work around your house (e.g. cleaning, cooking etc.)?	0	1	2	3	4
4.	During the past 2 weeks, how much has your sickness stopped you from doing other things that you need to do such as shopping?	0	1	2	3	4

IV.	Controlling My Sickness

For each of the following questions, please circle one number for each question that tells how you feel about doing things easily at this time:	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1.	I eat meals every 4 to 5 hours every day, including breakfast every day.	1	2	3	4	5
2.	I follow my diet and know what to eat when I am hungry.	1	2	3	4	5
3.	I exercise 15 to 30 minutes, 4 to 5 times a week.	1	2	3	4	5
4.	I know how to stop my blood sugar level from falling when I exercise.	1	2	3	4	5
5.	I know what to do when my blood sugar level goes higher or lower than it should be	1	2	3	4	5
6.	Feeling tired from being sick does not stop me from doing things that I want to do.	1	2	3	4	5
7.	Fear or worry from being sick does not stop me from doing things I want to do.	1	2	3	4	5
8.	I know my medications and take them everyday.	1	2	3	4	5
9.	I go for all my doctor appointments needed for my treatment.	1	2	3	4	5
10.	I know when the changes in my sickness mean I should go to my doctor.	1	2	3	4	5
V.	During the past week, how much total time did you spend on the following:

(check only one)	None	Less than 30 min/wk	30 - 60 min/wk	1 – 3 hrs/wk	More than 3 hrs/wk
1.	Stretching or using weights	1	2	3	4	5
2.	Walking for exercise	1	2	3	4	5
3.	Swimming	1	2	3	4	5
4.	Using exercise machine	1	2	3	4	5

VI.	Your Diet
1.	How many times last week did you eat breakfast when you got up?	________ times
2.	This morning, did you eat any of the following foods for breakfast? (check all that apply)

Milk (1/2 cup)	Cheese	Yogurt

Eggs	Meat, poultry, or fish	Beans

If you ate anything else, please write here: _________________________________________________

VII. Medications
1.	In the past week did you take pills for diabetes?	Yes No Don’t Know
2.	Please specify the name(s) of the diabetes pills you took: ___________________________________
3.	In the past week did you get insulin injections?	Yes No Don’t Know

VIII. Medical Care

When you go to your doctor:	(Circle one)
Never	Almost never	Some-times	Fairly often	Very often	Always
1.	Do you make a list of questions for your doctor?	0	1	2	3	4	5
2.	Do you ask questions about the things you want to know and things you don’t understand?	0	1	2	3	4	5
3.	Do you talk about things other than your being sick?	0	1	2	3	4	5

VIII. Medical Care, Continued
4.	In the past 2 months, how many times did you visit a doctor?

(Do not include hospital or ER visits)	________ visits
5.	In the past 2 months, how many times did you go to a walk-in-clinic for an emergency?	________ times
6.	In the past 2 months, how many times did you go to a hospital emergency room?	________ times
7.	In the past 2 months, how many times were you admitted to the hospital for one night or longer?	________ times
8.	When was the last time you had your eyes examined? (example: for glaucoma or any other problem)	_____ / _____

Month / Year
9.	How many times did the doctor or nurse examine your feet in the last 6 months?	________ times

IX. Check all that apply:
I am a participant with a sickness.	Yes	No
I take care of someone with a sickness.	Yes	No

X. Have you ever taken this class before?
Yes No Unsure

XI. This survey was completed: (check only one)
Without help With some help
Thank you for completing the survey!

“TAKE CONTROL OF YOUR HEALTH”

POST-WORKSHOP PARTICIPANT SURVEY

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MAR 16	Page 1

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2016-02-18

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