NEWS on Diabetes Survey (to be filled before beginning program/lessons)

Transcription

1 NEWS on Diabetes Survey (to be filled before beginning program/lessons) Region Agent Parish Date ID Seven digit phone number Please fill in the bubbles that correspond to your seven digit phone number by working your way down the rows. Please darken the circle that corresponds to your answer for each question. 1. Have you been diagnosed with diabetes? 2. If you have diabetes, how often do you check your blood sugar? nly when I m not feeling well Less than the number of times recommended by your health care professional As recommended by your health care professional 3. Which of the following is true about diabetes? (Select all that apply) Sugar causes diabetes. People with diabetes can t eat sugar. People with diabetes shouldn t eat any carbohydrates. Diabetes is caused when the body either can t make or use insulin properly. 4. Which one of the following is not a symptom of diabetes?

2 Frequent urination Excessive thirst Extremely energetic Blurry vision 5. Is there a diabetic diet? Don t know 6. Diabetes can cause which of these complications: (Select all that apply) Blindness Kidney disease Heart disease Amputations of limbs 7. Diabetes is best managed by which of the following: (Select all that apply) Diet Exercise Medications, if prescribed Don t know 8. When reading a food label, which is the most important to consider for effective blood sugar control? Total carbohydrates Sugar Fat Fiber Vitamins and minerals 9. Carbohydrates and starches are part of a healthy meal plan for diabetics and include which of the following foods? (Select all that apply) Milk and dairy Meat, fish and poultry Breads and grains Vegetables Fruits Fats

3 10. Which will have the greater effect on blood sugar? 1 teaspoon of sugar ½ cup potatoes Don t know 11. When looking at total carbohydrates on a food label, is it recommended to subtract one-half the grams of fiber from the total carbohydrate grams to get a better idea of the actual carbohydrate content of the food? Don t know 12. Choosing healthy snacks can be an important part of a diabetic meal plan? Don t know 13. If you have diabetes, which statement best shows your willingness to make lifestyle changes to manage your diabetes? I am not thinking about making any changes to manage my diabetes. I have started to think about making changes to manage my diabetes. I am ready to use my knowledge and skills to make permanent changes in my diabetes management. I have made changes in managing my diabetes during the past six months. I have sustained a management plan for my diabetes for more than six months. 14. The three key areas that will help treat, delay or prevent diabetes complications include which of the following: (Select all that apply) Education Early detection Regular doctor visits Taking supplements t eating sugar 15. As part of a diabetes management plan, how often are the following tests recommended? Daily Weekly Quarterly Yearly Blood glucose A1C Microalbumin Blood pressure

4 Cholesterol Weight 16. Suggested foods for a person with diabetes to keep on hand for sick days would include? (Select all that apply) Soup Fruit juice Crackers Mashed potatoes Peanut butter Frozen entrees Candy Chocolate chip cookies 17. How many minutes are you currently exercising most days of the week? t exercising at all Less than 30 minutes minutes minutes More than 60 minutes 18. If you have diabetes, how many visits have you made to a health care provider in the past six months because of diabetes-related complications/issues? 1-5 times 6-10 times times 16 or more times

5 NEWS on Diabetes Survey (to be filled out after completing lessons) Region Agent Parish Date ID Last four digits of home phone number Please fill in the bubbles that correspond to the last four digits of your home phone number by working your way down the rows. Please darken the circle that corresponds to your answer for each question. 1. Have you been diagnosed with diabetes? 2. If you have diabetes, how often do you check your blood sugar? nly when I m not feeling well Less than the number of times recommended by your health care professional As recommended by your health care professional 3. Which of the following is true about diabetes? (Select all that apply) Sugar causes diabetes. People with diabetes can t eat sugar. People with diabetes shouldn t eat any carbohydrates. Diabetes is caused when the body either can t make or use insulin properly.

6 4. Which one of the following is not a symptom of diabetes? Frequent urination Excessive thirst Extremely energetic Blurry vision 5. Is there a diabetic diet? Don t know 6. Diabetes can cause which of these complications: (Select all that apply) Blindness Kidney disease Heart disease Amputations of limbs 7. Diabetes is best managed by which of the following: (Select all that apply) Diet Exercise Medications, if prescribed Don t know 8. When reading a food label, which is the most important to consider for effective blood sugar control? Total carbohydrates Sugar Fat Fiber Vitamins and minerals 9. Carbohydrates and starches are part of a healthy meal plan for diabetics and include which of the following foods? (Select all that apply) Milk and dairy Meat, fish and poultry Breads and grains Vegetables Fruits Fats

7 10. Which will have the greater effect on blood sugar? 1 teaspoon of sugar ½ cup potatoes Don t know 11. When looking at total carbohydrates on a food label, is it recommended to subtract one-half the grams of fiber from the total carbohydrate grams to get a better idea of the actual carbohydrate content of the food? Don t know 12. Choosing healthy snacks can be an important part of a diabetic meal plan? Don t know 13. If you have diabetes, which statement best shows your willingness to make lifestyle changes to manage your diabetes? I am not thinking about making any changes to manage my diabetes. I have started to think about making changes to manage my diabetes. I am ready to use my knowledge and skills to make permanent changes in my diabetes management. I have made changes in managing my diabetes during the past six months. I have sustained a management plan for my diabetes for more than six months. 14. The three key areas that will help treat, delay or prevent diabetes complications include which of the following: (Select all that apply) Education Early detection Regular doctor visits Taking supplements t eating sugar 15. As part of a diabetes management plan, how often are the following tests recommended? Daily Weekly Quarterly Yearly Blood glucose A1C Microalbumin

8 Blood pressure Cholesterol Weight 16. Suggested foods for a person with diabetes to keep on hand for sick days would include? (Select all that apply) Soup Fruit juice Crackers Mashed potatoes Peanut butter Frozen entrees Candy Chocolate chip cookies 17. How many minutes are you currently exercising most days of the week? t exercising at all Less than 30 minutes minutes minutes More than 60 minutes 18. If you have diabetes, how many visits have you made to a health care provider in the past six months because of diabetes-related complications/issues? 1-5 times 6-10 times times 16 or more times If you would be willing to be contacted in six months to answer the previous question (Question 18) again, please fill out your contact information below. Thank you. Name: Address: Phone:

9 Follow-up Question for NEWS on Diabetes If you have diabetes, how many visits have you made to a health care provider in the past six months because of diabetes-related complications/issues? 1-5 times 6-10 times times 16 or more times