You at Risk for Diabetes? Are you overweight? Do Most people with diabetes do not notice any. signs. Diabetes Association (ADA). The OWH, NACDS, and …

DIABETES WELLNESS

AMERICAN INDIAN TALKING CIRCLES

Reservation: ________________________ Circle :___________________ Date: _______________ A DEMOGRAPHIC INFORMATION

What is your full name? Former Last: ___________________________ Former First: ___________________________ Former Middle: _________________________

Last: ____________________________ First: ____________________________ Middle: __________________________

Nickname/Other Name: _______________________________________________________ 2 To which IHS and non-IHS Hospital/Clinic do you usually go? List the one you go to most often first Hospital/Clinic Give names a ___________________________ b ___________________________ c ___________________________ d ___________________________ 3 What is your marital status? ____________ Never married ____________ Currently married ____________ Divorced ______________ Separated ______________ Widowed ______________ Adult roommate/partner Chart Number If medical _____________ _____________ _____________ _____________ IHS Yes or No ____________ ____________ ____________ ____________

A JOINT PROJECT OF
Center for American Indian Research Education CAIRE 1918 University Ave, Suite 2A
Berkeley, CA 94704-1051 510 843-8661 Fax 843-8611 Seva Foundation - Native American Diabetes Project PO Box 225 Winnebago, NE 68071 402 878-2392 Fax 878-2567

What is your current mailing address? Street/PO Box ____________________________________________________________ City/Town ________________________________________________________________ State and Zip Code _________________________________________________________

What is your home telephone number? Or at what telephone number can we leave a message? ____ ______ - __________ _______ Unlisted _______ No Phone

What is your work telephone? ____ ______ - __________ _______ Same as Home Phone _______ No Phone

Highest level of education: Completed Grade ______ or ______ HS Graduate or GED ______ Less than 4 year college ______ Completed college or any graduate school Blood quantum: Race Blood Quantum

Tribe 1: Tribe 2: White Black Hispanic Asian Other 9 10 Date of birth: ______________________________ Gender: ____ Male ____ Female

B DIABETES 11 Thinking of diabetes, what do you usually call this illness? ______________________________________________________________________________
______________________________________________________________________________ What does it do to you or your family? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

Please indicate if you agree or disagree with each statement: 13 I will probably get diabetes at some point in my life _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree There is nothing I can do to prevent getting diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree If someone has to take insulin shots for diabetes, their disease is very serious _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Once someone develops diabetes, there is nothing that can be done to prevent it from getting worse _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Children usually get Type I Diabetes and adults usually get
Type II Diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree 3

Diabetes tends to run in families _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree More American Indians get diabetes than any other ethnic group _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Cuts that are slow to heal and numbness in the toes occur in some people with diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree What you eat wont decide whether or not you get diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Increasing fiber and reducing fat and sugar are the three most important parts of a diet to prevent diabetes and for someone with diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Starchy foods, like bread, potatoes and rice, make people fat _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree
_________ Strongly disagree There are so many recommendations about healthy ways to eat, its hard to know what to believe _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree 4

What you eat can make a big difference in your chance of getting a disease, like heart disease, cancer or diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Its hard for me to get fruits and vegetables _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Exercise doesnt affect whether or not you get diabetes _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Diabetes can damage the eyes, kidneys, feet and heart _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree If someone has diabetes, they only need to take their medication when they feel bad _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree Medical care is so advanced today that no one gets their
feet or fingers amputated anymore _________ Strongly agree _________ Somewhat agree _________ Somewhat disagree _________ Strongly disagree

C WEIGHT SATISFACTION

Are you satisfied with your present weights? ______ YesGo to next page ______ No Do you want to lose or gain weight? ______ Lose ______ Gain Would you do so by: a b c d Eating Physical Activity Use of medication Other Less ___ Less ___ Less ___ Less ___ More ___ More ___ More ___ More ___ No change ___ No change ___ No change ___ No change ___

Please specify: ______________________________________________________________________________ ______________________________________________________________________________

D EATING PATTERNS 34 Please mark how often you eat at each of the following: Seldom Once Two or a times a Never Day Day _______ _______ _______ _______ _______ _______ _______

1-2 times a Week _______ _______ _______

3-5 times a Week _______ _______ _______

Fast food restaurants like McDonalds or Taco Bell

Family style restaurants _______ sit down with table service Social or family gatherings 35 _______

Please mark how often you prepare your food by each of the
following methods: Seldom Once Two 1-2 3-5 or a times a times a times a Never Day Day Week Week Baking ______ ______ ______ ______ ______ Boiling ______ ______ ______ ______ ______ Frying ______ ______ ______ ______ ______ Bar-B-Que ______ ______ ______ ______ ______ Drying ______ ______ ______ ______ ______ Broiling ______ ______ ______ ______ ______ 36 Which of the following foods do you think are high in fat? Please check all that apply _____ White Bread _____ Whole Milk _____Butter _____ Margarine _____ Cheese _____ Hamburger 37 _____ Chicken _____ French Fries _____Bananas _____ Salad Dressing _____ Mayonnaise _____ Fried Fish Sandwich _____ Fry Bread _____ Ritz Crackers _____Buffalo Meat _____ Bologna _____ Frozen Pizza

Which of the following foods do you think are high in fiber? Please check all that apply _____ Whole Wheat Bread _____ Skim Milk _____ Cheese _____ Broccoli _____ French Fries _____ Apples _____ Spaghetti _____ Green Salad _____ Salad Dressing _____ Bran _____Oatmeal _____Carrots _____ Frozen or Canned Vegetables _____ Buffalo Meat _____ Bananas

What kind of water do you drink at home? _____ Tap water _____ of glasses per day _____ Bottled water
_____ of glasses per day _____ Pescado _____ of glasses per day _____ Nutria Village well _____ of glasses per day _____ Nutria Box Canyon Spring _____ of glasses per day _____ Other sources: _____ of glasses per day Please name: ___________________________________________ Do you use a filter on your tap water? _____ Yes _____ No How many total glasses of water do you drink per day? _____ glasses How many cans or bottles of regular pop do you drink per day? _____ cans or bottles How many cans or bottles of diet pop do you drink per days? _____ cans or bottles

E PHYSICAL ACTIVITY

In terms of exercise, which of the following best fits your present situation? _____ I have no interest or plans to exercise regularly _____ In the past six months, I have repeatedly considered starting a physical fitness program but have not done so yet _____ I am currently trying to start a physical fitness program _____ I have recently started to exercise regularly _____ I routinely exercise and have done so for a long time In you exercise, how do you routinely get your physical fitness? _____ At the Wellness Center _____ Outdoor running _____ Outdoor walking _____ At home
on my own exercise equipment _____ Sport leagues: specify ________________________________________________ _____ My job/work: specify ________________________________________________ _____ Other: ______________________________________________________________ During the past month, how often did you participate in any physical activities or exercises like running, dancing, bicycling, vigorous walking, or basketball, separate from your regular job? _______ Times per week _______ Times per month _______ None

For how many minutes or hours do you usually keep at it? _______ minutes _______ hours

What type of activity or exercise did you spend the most time at during the past month? _____ running _____ dancing _____ bicycling _____ vigorous walking _____ basketball _____ baseball/softball _____ swimming _____ aerobics _____ gardening/yard work _____ housekeeping _____ other specify _______________________________________________________ 9

Do you think these statements about exercise are true or false? 48 All benefits to the heart and lungs from regular exercise are lost over time if exercise is not kept up _____ True _____ False Regular exercise usually weakens the
bones _____ True _____ False Regular exercise helps get rid of body fat _____ True _____ False Regular exercisers are more likely to have heart attacks _____ True _____ False Exercises that cause fast breathing for a long time are better for health that short, hard bursts of exercise _____ True _____ False Sweating a lot while exercising usually means you are exercising too hard _____ True _____ False Most experts recommend that exercise be done for at least one hour each time _____ True _____ False How many hours a day do you spend watching TV? _____ Hours

F TOBACCO

Have you smoked at least 100 cigarettes in your entire life? 100 cigarettes 5 packs _____ Yes _____ NoGo to Q66 on the next page Do you now smoke cigarettes every day, some days, or not at all? _____ every day _____ some days _____ not at allGo to Q66 on the next page On which occasions are/were you most likely to smoke, or increase your smoking? Please read the list and check the appropriate response Yes No a stressful times b casinos c wakes/funerals d when drinking alcohol e social meetings f when you have extra money g bingo ____ ____ ____ ____ ____ ____ ____ ____ ____ ____
____ ____ ____ ____

i other, specify: ___________________________________________________________ 59 On average, about how many cigarettes a day do you now smoke? ______ cigarettes ______ Dont smoke regularly 60 On occasions that your smoking increased, how many cigarettes do/did you smoke per day? __________ What brand of cigarettes do you smoke? __________________________________________

Are you planning to quit smoking in the next 30 days? _____ Yes _____ No Do you smoke inside the house? _____ Yes _____ No Do you smoke at work? _____ Yes If yes, do you smoke indoors? ____________ _____ No or outdoors? ____________ About how old were you when you smoked your first whole cigarette? _________ years

During the past week, how many days did anyone smoke cigarettes, cigars or pipes anywhere around your home? _____ days per week How many smokers are in your household? ____________________________ Is smoking allowed inside your house home? _____ Yes _____ No Are visitors allowed to smoke inside your house? _____ Yes _____ No Whether or not you smoke, on the average, how many hours a day are you exposed to the smoke of others? if none, please fill
in zero; enter 1 hour if 30 min or more, enter 0 if less than 30 min _____ Hours Do you currently use chewing tobacco? _____ Yes _____ No

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G CULTURAL IDENTITY 72 What is your religious affiliation? _____ Christian _____ Indian religion _____ Other specify ______________________________________________________ _____ None Can you speak your tribal Indian language? _____ Yes What is it called? ________________________________________________ _____ NoGo to Q76 on this page Can you speak this language fluently? _____ Yes _____ No Do you speak your tribal language at home? _____ Always _____ Sometimes _____ Never Do others speak your tribal language in your home? _____ Always _____ Sometimes _____ Never How often do you participate in traditional Indian practices such as memorials, feasts, healing ceremonies, religious events, festivals, or pow wows? _____ Never _____ Rarely _____ Sometimes _____ Often _____ Always Are these traditional practices specific to your Indian tribe? _____ Most of them _____ Some of them _____ None of them How you ever participated in an Indian tribal healing ceremony? _____ Yes _____ No Do you feel connected to your American Indian
community? _____ Yes _____ No 13

H MEDICAL HISTORY 81 Has a health care provider ever told you that you had any of the following health problems: YES A B C D E F G H I J Lung disease, including asthma, emphysema, chronic bronchitis Heart disease Hypertension High Blood Pressure Liver disease including cirrhosis Arthritis Gallstones Depression Mental illness stroke Vision problems If YES for Vision problems, what type? NO Are you getting treatment now?

K Cancer If YES for Cancer, what type? L Kidney disease If YES for Kidney disease, are you on renal dialysis? _____ Yes _____ No Have you ever had a kidney transplant? _____ Yes _____ No If YES for kidney transplant, is the new kidney working well? _____ Yes _____ No Are you waiting for a kidney transplant? _____ Yes _____ No

M Diabetes If YES for Diabetes, complete DIABETES HISTORY at end N Any others?

I ACCESS TO MEDICAL CARE In the past 5 years have you received any medical care at: YES NO 82 Source of medical care: a IHS facility b c d e f g h i 83 Tribal facility Private facility Private practitioner Traditional healer VA/military facility Health Maintenance Organization HMO ____ ____ ____
____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ What is your usual source medical care Check only one ____ ____ ____ ____ ____ ____ ____

Other, list ___________________________ Nowhere ____ ____ ____

In addition to IHS coverage, what health insurance do you have? Check all that apply _____ None _____ Veteran/military hospital _____ Private Health Insurance _____ HMO _____ Medicaid _____ Medicare _____ Other, list _________________________ How do you get to your usual healthcare provider? Check only one _____ Myself _____ Community Health Representative CHR_ _____ Family member _____ Paid driver _____ Friend

J QUALITY OF LIFE 85 In general, would you way your health is: Please check only one _____ Excellent _____ Very good _____ Good _____ Fair _____ Poor Compared to one year ago, how would you rate your health in general now? Please check only one _____ Much better than one year ago _____ Somewhat better than one year ago _____ About the same _____ Somewhat worse than one year ago _____ Much worse than one year ago

These next questions are about limitations you may have in your daily life 87 Are you limited in any way in any activities because of any
impairment or health problem? _____ Yes _____ NoGo to Q91 on next page What is the one major impairment or health problem that limits your activities? _____ Arthritis/rheumatism _____ Back or neck problem _____ Fractures, bone/joint injury _____ Waling problem _____ Lung/breathing problem _____ Hearing problem _____ Eye/vision problem _____ Heart problem _____ Stroke problem _____ Hypertension/high blood pressure _____ Diabetes _____ Cancer _____ Depression/anxiety/emotional problem _____ Obesity _____ Other impairment/problem ________________________________________________ Is this impairment or health problem the result of a work-related illness or injury? _____ Yes _____ No 16

For how long have your activities been limited because of your major impairment or health problem? _____ Days _____ Weeks _____ Months _____ Years Because of any impairment or health problem, do you need the help of other persons with your PERSONAL CARE needs, such as eating, bathing, dressing, or getting around the house? _____ Yes _____ No Because of any impairment or health problem, do you need the help of other persons in handling your ROUTINE needs, such as everyday household chores,
doing necessary business, shopping or getting around for other purposes? _____ Yes _____ No During the past 30 days, for about how many days did pain make it hard for you to do your usual activities, such as self-care, work or recreation? _____ Number of days _____ None During the past 30 days, for about how many days have you felt sad, blue or depressed? _____ Number of days _____ None During the past 30 days, for about how many days have you felt worried, tense or anxious? _____ Number of days _____ None During the past 30 days, for about how many days have you felt you did not get enough rest or sleep? _____ Number of days _____ None During the past 30 days, for about how many days have you felt very healthy and full of energy? _____ Number of days _____ None

Mark the statement within each item that best describes the way you feel today, namely, the way you are feeling right now Be sure to read all the statements in each item before selecting one 98 _____ I do not feel sad _____ I feel sad _____ I am sad all the time and I cant snap out of it _____ I am so sad or unhappy that I cant stand it _____ I am not particularly discourage about the future
_____ I fell discouraged about the future _____ I feel I have nothing to look forward to _____ I feel that the future is hopeless and that things cannot improve _____ I do not feel like a failure _____ I feel I have failed more than the average person _____ As I look back on my life, all I can see are a lot of failures _____ I feel I am a complete failure as a person _____ I get as much satisfaction out of things as I used to _____ I dont enjoy things the way I used to _____ I dont get real satisfaction out of anything anymore _____ I am dissatisfied or bored with everything _____ I dont feel particularly guilty _____ I feel guilty a good part of the time _____ I feel quite guilty most of the time _____ I feel guilty all of the time _____ I dont feel I am being punished _____ I feel I may be punished _____ I expect to be punished _____ I feel I am being punished _____ I dont feel disappointed in myself _____ I am disappointed in myself _____ I am disgusted with myself _____ I hate myself worse than anybody else _____ I dont feel I am any worse than anybody else _____ I am critical of myself for my weaknesses and mistakes _____ I blame myself all the time for my faults _____ I blame
myself for everything bad that happens

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_____ I dont have any thoughts of killing myself _____ I have thoughts of killing myself, but I would not carry them out _____ I would like to kill myself _____ I would kill myself if I had the chance _____ I dont cry any more than usual _____ I cry more now than I used to _____ I cry all the time _____ I used to be able to cry, but now I cant cry even though I want to _____ I am no more irritated by things than I ever am _____ I am slightly more irritated now than usual _____ I am quite annoyed or irritated a good deal of the time _____ I feel irritated all the time now _____ I have not lost interest in other people _____ I am less interested in other people than I used to be _____ I have lost most of my interest in other people _____ I have lost all of my interest in other people _____ I make decisions about as well as I ever could _____ I put off making decisions more than I used to _____ I have greater difficulty in making decisions than before _____ I cant make decisions at all anymore _____ I dont feel that I look any worse than I used to _____ I am worried that I am looking old or unattractive
_____ I feel that there are permanent changes to my appearance that make me look unattractive _____ I believe that I look ugly _____ I can work about as well as before _____ It takes an extra effort to get started at doing something _____ I have to push myself very hard to do anything _____ I cant do any work at all _____ I can sleep as well as usual _____ I dont sleep as well as I used to _____ I wake up one or two hours earlier than usual and find it hard to get back to sleep _____ I wake up several hours earlier than I used to and cannot get back to sleep

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_____ I dont get more tired than usual _____ I get tired more easily than I used to _____ I get tired from doing almost anything _____ I am too tired to do anything _____ My appetite is no worse than usual _____ My appetite is not as good as it used to be _____ My appetite is much worse now _____ I have no appetite at all anymore _____ I havent lost much weight, if any lately _____ I have lost more than five pounds _____ I have lost more than ten pounds _____ I have lost more than fifteen pounds _____ I am no more worried about my health than usual _____ I am worried about physical
problems such as aches and pains or upset stomach or constipation _____ I am very worried about physical problems and its hard to think of much else _____ I am so worried about my physical problems that I cannot think about anything else

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K ALCOHOL

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When you drink, how much do you usually drink? ___________ Drinks a How many times per month do you drink that much? _____________ Times per Month

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When was your last drink? _____ Within the last week _____ Within the last month _____ Within the last year: Number of months ago _____ _____ More than a year ago: Number of years ago _____ _____ Never Have you ever been treated for problems from alcohol or drugs? _____ Yes _____ No How does alcohol affect diabetes medication and blood sugar? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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L INCOME 122 Does your household income meet your familys needs? _____ Yes _____ No What is your MAIN daily activitys? Please list up to three main activities ________ Main
________ Second _________ 3rd 1 Caring for Family 2 Working for Pay/Profit 3 Going to School 124 4 Looking for Work 5 Retired/Elderly 6 Other, specify: _____________________________

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Are you currently employed? _____ Yes _____ NoGo to Q127 on this page Is your employment _____ Full-time? _____ Part-time? _____ More than one job? _____ Seasonal? _____ Some other kind of employment? specify ____________________________________ What type of work do you do? ______________________________________________________________________________ ______________________________________________________________________________ In the past 12 months, did your family receive any kind of economic assistance or food assistance? _____ Yes _____ No Including yourself, how many people live in your household? _________ people What are their ages? _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

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What is your combined all working members annual household income before taxes? _____ Less than 5,000 _____ 5,000 to 9,999 _____ 10,000 to 19,999 _____ 20,000 to 29,000 _____ 30,000 to more In the past year, have you had to borrow money to pay basic living expenses
such as food, mortgage/rent, because of gambling losses? _____ Yes _____ No

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M DIABETES HISTORY ANSWER THESE QUESTIONS ONLY IF YOU ANSWERED YES TO Q81 for DIABETES: YES, a health care provider has told me I have diabetes 131 Do you still have diabetes? _____ Yes _____ No How old were you when you were first told by a medical person that you had diabetes? _____ Years old Have you had loss of feeling in your fingers or toes? _____ Yes _____ No Have you had any amputations due to any diabetes complications? _____ Yes _____ No What type of treatment are you taking for your diabetes? Check appropriate answers YES NO a b c d e f g insulin oral hypoglycemic agent dietary control exercise Native medicines do nothing other: _________________________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

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What did your doctor tell you to do for your diabetes? Check appropriate answers YES NO a b c d e f g insulin oral hypoglycemic agent dietary control exercise Native medicines do nothing other: _________________________ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____

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Has diabetes
medication ever been prescribed for you? _____ Yes _____ NoGo to Q140 on this page Was it _____ oral medication or _____ insulin injection When did you start taking this medicine for diabetes? _____ weeks ago or _____ months ago or _____ years ago or _____ Have not started When was the last time a medical person taught you about the following: 0-1 Year 1 Years a Cause of diabetes _____ _____ b Foot and skin care _____ _____ c Urine/blood testing _____ _____ d Insulin _____ _____ e Diet _____ _____ f Exercise _____ _____ How often do you inspect your feet? _____ Daily _____ 3-6 days per week _____ 1-3 days per week _____ Less than once per week _____ Never 25

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Do you have corns or calluses on your feet? _____ Yes _____ No Do you test your blood glucose? _____ Yes _____ NoGo to Q147 on this page How often do you test your blood glucose? _____ Never Why? _______________________________________________ _____ Once daily _____ Twice daily _____ 3 or more times daily _____ Spot checks such as when ill Do you keep records of your tests? _____ Yes, regularly _____ Yes, during atypical situations _____ No Do you usually
perform tests before or after meals? _____ Before meals _____ After meals Do you usually use medication to control your diabetes? _____ Yes _____ NoGo to Q154 on next page Which of the following types of medications do you usually take? _____ Insulin _____ Oral medicationsIf only take oral medications, go to Q154 on next page What strength of insulin do you usually use? _____ U-100 _____ Other Do you ever take insulin at times other than those prescribed by your doctor? _____ Yes Why? ___________________________________________________________ _____ No

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Do you usually rotate your insulin injection? _____ Yes What sites do you generally rotate? ______________________________________ _____ No Do you usually inject your own insulin? _____ Yes _____ No Who does? ___________________________________________________________ Do you often find you need to increase or decrease the amount of your insulin dosage? _____ Yes _____ No During the last month: a _____ How many mild insulin low blood sugar reactions have you had? b _____ How many severe insulin reaction have you had that required assistance? c _____ How many times did you call the
doctor about these reactions? d _____ How many times did you go to the hospital, emergency room, or doctor because of these reactions? When away from your home or work, do you carry anything for treating insulin reactions? _____ Yes What? _______________________________________________________ _____ No Have you told your friends, family and co-workers how to take care of you in case of a reaction? _____ Yes _____ No Do you have identification bracelet, necklace or card which identifies you as a diabetic? _____ Yes, on person _____ Yes, not on person _____ No Do you follow a diabetic diet? _____ Yes Calories per day _____________________ _____ No Do you usually weigh or measure your food portions? _____ Yes _____ No

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For the rest of the questions, mark the best answer: 160 In an insulin reaction is suspected: _____ Take black coffee, tea or diet cola to treat the reaction, or _____ Eat a quick acting sugar followed by a protein snack, or _____ Call your doctor immediately One small apple can be exchanged for: _____ One half cup of cucumbers, or _____ One medium peach, or _____ Two bananas The treatment of diabetes includes: _____ Weight
control, or _____ Long and frequent rest periods, or _____ Surgery on the pancreas When a person has diabetes, the amount of sugar in his blood is due to: _____ Eating too much sugar and other sweet foods, or _____ Failure of the pancreas to make enough insulin, or _____ Failure of the kidneys to control sugar in the urine The best way for people with diabetes to take care of their feet is to: _____ Wash feet every day with hot water, dry feet well, and use a nail file to trim toes, or _____ Wash feet every day with warm water, dry feet well, and cut toenails straight across regularly, or _____ Wash feet every day with warm water and keep warm with a hot water bottle at night People with diabetes should call the doctor if: _____ There is sugar in the urine for two weeks in a row, or _____ A fever is present, or _____ They are unable to eat the regular prescribed diet for 24 hours Do all types of insulin have the same action time? _____ Yes _____ No Should a diabetic increase the insulin dose if planning to exercise? _____ Yes _____ No

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When becoming weak and shaky, should a diabetic eat some hard candy? _____ Yes _____ No When I go to the
doctors office, I usually have to wait a long time _____ Yes _____ No I feel that I can ask the doctor questions whenever I want to ask questions _____ Yes _____ No I often feel I can look after myself better than the doctors _____ Yes _____ No I have a lot of faith in the doctors I usually see _____ Yes _____ No I dont tell other people about having diabetes until I am very close to them _____ Yes _____ No I cant manage my life around the diabetes management plan _____ Yes _____ No I dont have many good things to look forward to in life _____ Yes _____ No I can do almost everything that people who do no have diabetes can do _____ Yes _____ No

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Source:seva.org