DIABETES. You may use all or parts of the questionnaire at no charge without permission Please specify the name(s) of the diabetes pills you took: …
Stanford Patient Education Research Center
Stanford University School of Medicine
SAMPLE QUESTIONNAIRE
DIABETES
You may use all or parts of the questionnaire at no charge without permission Stanford Patient Education Research Center 1000 Welch Road, Suite 204 Palo Alto CA 94304 650 723-7935 voice 650 725-9422 fax http://patienteducationstanfordedu self-management@stanfordedu
Name: Address: City, state, zip: Telephone: home work __
Todays date:
Date of birth: Sex: Female Male
Background
1 Ethnic origin check White not Hispanic Black not Hispanic Hispanic only one: Asian or Pacific Islander Filipino American Indian/Alaskan Native Other: __________________________
2 Please circle the highest year of school completed: 123456
primary
7 8 9 10 11 12
high school
13 14 15 16
college/university
17 18 19 20 21 22
graduate school
23
3 Are you currently check married single
only one: separated divorced widowed
4 Please indicate below which chronic conditions you have: Diabetes type 2 Heart disease Lung disease Diabetes type 1 Type of heart disease: Type of lung disease: High cholesterol High blood pressure
Other chronic condition Specify:
2
General Health
1 In general,
would you say your health is: Circle one Excellent 1 Very good2 Good3 Fair 4 Poor 5
Symptoms
How much time during the past month
None of the time A little of the time Some of the time A good bit of the time Most of the time All of the time
1 Were you discouraged by your health problems? 0 2 Were you fearful about your future health? 0 3 Was your health a worry in your life? 0 4 Were you frustrated by your health problems? 0
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
5 5 5 5
5 We are interested in learning whether or not you are affected by fatigue Please circle the number below that describes your fatigue in the past 2 weeks:
No fatigue
0
1
2
3
4
5
6
7
8
9
Severe fatigue
10
3
6 We are interested in learning whether or not you are affected by pain Please circle the number below that describes your pain in the past 2 weeks
0
No pain
1
2
3
4
5
6
7
8
9
10
Severe pain
7 We are interested in learning whether or not you are affected by shortness of breath Please circle the number below that describes your shortness of breath in the past 2 weeks:
No shortness of breath
0
1
2
3
4
5
6
7
8
9
Severe shortness of breath
10
In the PAST WEEK, did you ever
have any of the following symptoms 8 Increased thirst? 9 Dry mouth? 10 Decreased appetite? 11 Nausea or vomiting? 12 Abdominal pain? 13 Frequent urination at night? Do you have to get up to urinate 3 or more times a night? 14 Severely high blood sugar blood glucose readings of 300 mg or higher? 15 Morning headaches? No No No No No No No No Yes Yes Yes Yes Yes Yes Yes Yes Dont know Dont know Dont know Dont know Dont know Dont know Dont know Dont know 4
In the PAST WEEK, did you ever have any of the following symptoms 16 Nightmares? 17 Night sweats? 14 Lightheadedness? 18 Shakiness or weakness? 19 Intense hunger? 20 Times when you passed out fainted or lost consciousness, even for a short time? No No No No No No Yes Yes Yes Yes Yes Yes Dont know Dont know Dont know Dont know Dont know Dont know
Daily Activities
During the past 4 weeks, how much
Not at all Slightly Circle one Moderately Quite a bit Almost totally
1 Has your health interfered with your normal social activities with family, friends, neighbors or groups?0 2 Has your health interfered with your hobbies or recreational activities? 0 3 Has your health interfered with your household chores? 0 4 Has your health
interfered with your errands and shopping? 0
1 1 1 1
2 2 2 2
3 3 3 3
4 4 4 4
Your Glucose Testing
1 Do you have a machine to measure your blood sugar glucose level? Yes No
2 On 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 On days that you test your blood sugar, how many times do you test on average? _______ times
5
Physical Activities
During the past week, even if it was not a typical week for you, how much total time for the entire week did you spend on each of the following? Please circle one number for each question
none less than 30 min/wk 30-60 min/wk 1-3 hrs per week more than 3 hrs/wk
1 Stretching or strengthening exercises range of motion, using weights, etc 0 2 Walk for exercise 0 3 Swimming or 
aquatic exercise 0 4 Bicycling including stationary exercise bikes0 5 Other aerobic exercise equipment Stairmaster, rowing, skiing machine, etc 0 6 Other aerobic exercise Specify_________________________ 0
1 1 1 1 1
2 2 2 2 2
3 3 3 3 3
4 4 4 4 4
1
2
3
4
Confidence About Doing Things
For each of the following questions, please circle the
number that corresponds with your confidence that you can do the tasks regularly at the present time
________________________________ 1 How confident do you feel that you can eat your Not at all | | | | | | | | | | Very meals every 4 to 5 hours every day, including confident 1 2 3 4 5 6 7 8 9 10 confident breakfast every day?
2 How confident do you feel that you can follow your diet when you have to prepare or share food with other people who do not have diabetes?
________________________________ Not at all | | | | | | | | | | Very confident 1 2 3 4 5 6 7 8 9 10 confident
________________________________ 3 How confident do you feel that you can chose the Not at all | | | | | | | | | | Very appropriate foods confident 1 2 3 4 5 6 7 8 9 10 confident to eat when you are hungry for example, snacks? ________________________________ 4 How confident do you feel that you can exercise Not at all | | | | | | | | | | 15 to 30 minutes, 4 to 5 times a week? confident 1 2 3 4 5 6 7 8 9 Very 10 confident
5 How confident do you feel that you can do something to prevent your blood sugar level from dropping when you exercise? 6 How confident do you feel that you know
what
________________________________ Not at all | | | | | | | | | | Very confident 1 2 3 4 5 6 7 8 9 10 confident
Not at all
________________________________ | | | | | | | | | |
Very
6
to do when your blood sugar level goes higher or confident 1 lower than it should be? 7 How confident do you feel that you can judge when the changes in your illness mean you should visit the doctor? 8 How confident do you feel that you can control your diabetes so that it does not interfere with the things you want to do?
2
3
4
5
6
7
8
9
10 confident
________________________________ Not at all | | | | | | | | | | Very confident 1 2 3 4 5 6 7 8 9 10 confident ________________________________ Not at all | | | | | | | | | | Very confident 1 2 3 4 5 6 7 8 9 10 confident
Your Diet
1 How many times last week did you eat breakfast when you got up? __ times last week
2 This morning, did you eat any of the following foods for breakfast? Please check all that apply milk cup eggs cheese meat, poultry, or fish yogurt beans
If you ate anything else, please write here:
Medications
1 In the past week did you take pills for diabetes? Please specify the names of the diabetes pills you took: 2
In the past week did you get insulin injections? 3 In the past week did you take pills for high blood pressure? No No Yes Yes Dont know Dont know No Yes Dont know
Please specify the names of the blood pressure pills you took: 4 In the past week did you take pills for cholesterol? Please specify the names of the cholesterol pills you took: No Yes Dont know
7
Medical Care
1 When you visit your doctor, how often do you do the following please circle one number for each question:
Never Almost never Sometimes Fairly often Very often Always
a Prepare a list of questions for your doctor 0 b Ask questions about the things you want to know and things you dont understand about your treatment0 c Discuss any personal problems that may be related to your illness 0
1
2
3
4
5
1 1
2 2
3 3
4 4
5 5
2 In the past 6 months, how many times did you visit a physician? Do not include visits while in the hospital or the hospital emergency department__________ visits 3 In the past 6 months, how many times did you go to a hospital emergency department?__________ times 4 In the past 6 months, how many TIMES were you hospitalized for one night or longer? __________ times a How many total
NIGHTS did you spend in the hospital in the past 6 months? __________ nights b Were any of these hospitalizations at a skilled nursing facility, convalescent hospital, or other minimum care facility? 5 When was the last time you had your eyes examined? example: for glaucoma or any other problem Month Yes No
Year
6 How many times did the doctor or nurse examine your feet in the last 6 months? _____________ times
Thank you for your help
8
Source:wormwoman.com
