ID # _____
1
County: __________________
Date:_____________
(Official Use Only)
Eat Well, Be Well with Diabetes – Pre- Session Questionnaire
Please help us determine if Eat Well, Be Well with Diabetes is useful by completing this short survey.
1.
a.
b.
c.
d.
e.
f.
2.
How often do you do the following? Check only one response for each item.
Never A few
Once
2 -3
times per per
times per
month
week
week
Eat whole grains such as whole grain
bread, whole wheat pasta, whole grain
cereal, oatmeal, and/or brown rice.
Eat meat/poultry high in animal fat such as
bacon, sausage, chicken with skin, hot dogs,
salami, bologna, steak marbled with fat,
pepperoni, hamburger (with 20% or more
fat).
Drink sugar sweetened drinks (non-diet)
such as regular soda, tea sweetened with
sugar, lemonade, hot chocolate, fruit drinks.
Use the Nutrition Facts label on packaged
foods when choosing what to eat.
Do moderate physical activity such as fast
walking, biking, swimming, and/or lifting for
at least 30 minutes at a time.
Prepare healthy meals for yourself.
Most
days per
week
Check only one answer for each of the following questions.
a. On most days, how many servings of
vegetables do you eat per day?
None
1
2
3
4 or more
b. On most days, how many servings of fruit do
you eat per day?
None
1
2
3
4 or more
c When someone has diabetes, the number of
servings of carbohydrate that are best for that
individual is based on:
Weight
Activity level
Diabetes medications
Blood glucose level goals
All of the above
d. A carbohydrate serving is about____ grams
of carbohydrate.
5
10
15
20
e. Which of the following does NOT provide
carbohydrates?
Milk
Peas
Sugar
Chicken
f.
Which of the following carbohydrate foods is
a good source of fiber?
White rice
Orange juice
Mashed potatoes
Dried beans
Go to Page 2
2
Do you have diabetes?
YES
NO
If you do NOT have diabetes, please, skip to Page 3 (Question #9).
3. Do you agree or disagree with the following statements? Check only one response for each
item.
SA = Strongly Agree, A = Agree, U= Unsure, D=Disagree, SD Strongly Disagree
SA
A
U
D
SD
a. I am confident about my ability to prepare healthy meals
for myself or for someone else with diabetes.
b. I feel confident about making good choices about taking
care of my diabetes.
c. I feel confident I can try out different ways of overcoming
barriers to my diabetes goals.
d. I feel confident I can turn my diabetes goals into a
workable plan.
e. I feel confident I can ask for support for caring for my
diabetes when I need it.
f. I feel confident about my ability to make healthy food
choices when eating out.
g. I feel confident I can talk to my health care provider about
questions I have about my diabetes.
h. I feel confident I can use carbohydrate counting and/or the
plate method to plan my meals and snacks.
4. How often do you do the following? Check only one response for each item.
a.
b.
c.
d.
N= Never, R=Rarely, S= Sometimes, F=Frequently A =Always
N
R
S
F
A
Eat about the right amount of food to keep your blood
sugars in a normal range at most meals and snacks.
Take your medications as prescribed.
Don’t have prescribed medicines
Check your blood sugar levels as recommended.
Provider did not recommend checking
Check your feet for cuts, blisters, sores, etc. daily.
5. How long have you been diagnosed with
diabetes?
Less than 6 months
6 months to a year
1-2 years
3-5 years
More that 5 years
6. When did you last talk with a health care
professional about your diabetes?
Within the last 6 months
6 months to a year ago
2-5 years ago
More than 5 years ago
Never
7. When was the last time you had an A1C
test (measures your average blood
glucose)?
Within the last three months
Within the last six months
Within the last year
More than a year ago
I don’t know
8. Are you taking medication for your
diabetes? (Check one)
Yes, pills only
Yes, both pills and insulin
Yes, insulin only
No, I manage my diabetes with diet
and exercise only
Go to Page 3
3
9. Gender
Male
Female
10. What is your marital status?
Never married
Married
Living with a partner
Separated/divorced
Widowed
11. Employment Status: (check one)
Employed full-time or Self-employed
Employed part-time
Unemployed
A Homemaker
A Full-time student
Retired
Other ________________
12. Number of people living in your
household including yourself: (check
one)
Just myself
2 people
3 people
4 people
5 people
6 or more people
13. Age (check one)
Under 18
18-24
25-45
46-64
65 +
14. What level is your annual household
income from all sources? (check one)
Less than $15,000
$15,000-$24,999
$25,000-$49,999
$50,000-$99,999
$100,000 +