ID # _____
Date:__________
County:_____________________
(Official Use Only)
Eat Well, Be Well with Diabetes – Follow-Up 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.
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 weights
for 30-60 minutes a day.
Prepare healthy meals for yourself.
Most
days per
week
2. Check 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
Do you have diabetes?
YES
NO
If you do not have diabetes, please, skip to question #9.
3. Do you agree or disagree with the following statements? Check only one response for each.
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.
N= Never, R=Rarely, S= Sometimes, F=Frequently A =Always
N
R
S
F
A
a. Eat about the right amount of food to keep your blood
sugar in a normal range at most meals and snacks.
b. Take your medications as prescribed.
Don’t have prescribed medicines
c. Check your blood sugar levels as recommended.
Provider did not recommend checking
d. Check your feet for cuts, blisters, sores, etc. daily.
5. 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
7. If you have had an A1C test in the last 3
months, did your A1C improve?
Yes…..by how much? _____________
No
I have not had an A1C test in the past 3
months.
6. When was the last time you had an A1C
test (measures 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?
Yes, pills only
Yes, both pills and insulin
Yes, insulin only
No, I manage my diabetes with diet and
exercise only
9. How many of the recipes have you used from class or the recipe booklet you received? (circle one)
None
1-2
3-5
6-9
10 or more
10. Please share two ways this program has changed your life?
11. Is there anything else you want to tell us about this class? (Use back of page).
Thank you!