This survey asks what you think about your diabetes. I thought about what I could do to control my diabetes. I called a health care provider about my diabetes …
Diabetes Survey
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|Has a doctor or nurse ever told you that you have diabetes? |
| |
|0 No - Please return the survey in the enclosed self-addressed, |
|postage-paid envelope Do not complete this survey Thank you |
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|1 Yes - Please continue with the questions and instructions below Mail |
|your completed survey in the enclosed postage-paid, self-addressed |
|envelope |
Instructions for filling out this survey
This survey asks what you think about your diabetes Your response is very
important and the information you provide will be used to improve diabetes
care Please answer every question by filling in the appropriate box or
circling the appropriate number If you are unsure about an answer, please
give the best answer you can Results of this survey are confidential and
will not change your current health care
1 In
general, how serious would you say the disease diabetes is?
Not serious The most serious
at all Average thing I know
1 2 3 4 5 6 7 8 9 10
2 How serious would you say your diabetes is?
Not serious The most serious
at all Average thing I know
1 2 3 4 5 6 7 8 9 10
3 Overall, how good is your diabetes control?
Totally out Great, the best
of control Average control
possible
1 2 3 4 5 6 7 8 9 10
4 Do you agree with the following statement I go to the doctor more often
because of my diabetes than people without diabetes
1 Strongly agree
2 Agree
3 Neutral
4 Disagree
5 Strongly disagree
5 How would you complete this statement? Because of my diabetes,
_________ money is spent on my health care than people without diabetes
check one box
1 More
2 About the same
3 Less
7 Dont know
6 a In the last 4 years, have you ever heard or seen this message:
1 Yes
0 No
7 Dont know
b Where did you see or hear that message? check all that apply
I did not see or hear the message Health plan
newsletter
Doctors office/clinic Radio
Diabetes educators office Website
Television Newspaper/magazine
Pharmacy
Other specify: ___________________________________________
7 What did you do as a result of seeing or hearing that message? check
all that apply
I did not see or hear the message
I did nothing as a result of seeing this message
I thought about calling a health care provider
I thought about what I could do to control my diabetes
I called a health care provider about my diabetes
I changed one or more of my behaviors to control my diabetes for
example, check blood sugar more often, changed what I eat, changed
my physical activity
I am already doing things to control my
diabetes
Other specify:
8 What things prevent you from controlling your diabetes the way you want?
check all that apply
Lack of time
Cost
Insurance doesnt cover needed supplies/doctor visits
Lack of transportation to get to diabetes-related appointments
Lack of childcare
Other things are more important to me
Lack of support from family, friends, or doctor
Dont know how to control my diabetes
Other
Nothing
9 What year were you born?
10 Are you of Spanish or Hispanic ancestry?
1 Yes
0 No
11 Which of the following best describes your primary racial background?
1 American Indian or Alaska Native
2 Black or African American
3 White or Caucasian
4 Asian Indian
5 Chinese
6 Japanese
7 Korean
8 Vietnamese
9 Guamanian or Chamorro
10 Native Hawaiian
11 Filipino
12 Samoan
13 Other Asian
14 Other Pacific Islander
15 Other
Thank you for your help
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Source:doh.wa.gov
