Personal Diabetes Questionnaire
Personal Diabetes Questionnaire
Name ____________________________________ Date ___________________
To provide you with the best possible care, we want to know what topics you would like to discuss today. In addition, we need to know about your recent eating habits, medicines, blood glucose testing, and your physical activity. Answer each question as accurately as possible. We will use your answers to help you solve any problems you are having managing your diabetes.
We need some basic information about you and your diabetes.
1. Are you (check one)
_____ Male
_____ Female
2. How old are you? __________ years old
3. How tall are you? __________ feet __________ inches
4. How much do you weight? __________ pounds
5. What is your desired weight? What do you think would be a good, realistic weight for you? __________
A. Perceived Blood Glucose Control
1. How satisfied are you with your overall blood glucose control
_____ I have excellent control
_____ I have pretty good control
_____ I have good control
_____ I have a few problems
_____ I have poor control
_____ I have very poor control
2. Do you have a target range for your blood glucose? That is, do you try to keep your blood sugar from getting lower or higher than certain values that you and your doctor or nurse have agreed on?
_____ Yes
_____ No
_____ Not sure
3. Sometimes when you test your blood sugar, it can be too high. How often is this a problem for you?
_____ My blood sugar is never too high
_____ A couple times a month or less
_____ Once or twice a week
_____ Three to five times a week
_____ Almost every day
4. Sometimes blood sugar can be two low causing hypoglycemia (an insulin reaction). How often is this a problem for you?
_____ My blood sugar is never too high
_____ A couple times a month or less
_____ Once or twice a week
_____ Three to five times a week
_____ Almost every day
B. Weight Change Readiness. Readiness for Change for Attempting Weight Loss.
1. Are you currently trying to lose weight?
_____ Yes, I am trying to lose weight
_____ No, but I am trying to keep from gaining weight
_____ No, I am not making any attempts to control my weight now.
2. If you are NOT currently trying to lose weight or avoid gaining weight, is this something you plan to do in the future?
_____ Yes, I plan to start within the next month
_____ Yes, I plan to start within the next six months
_____ No, I have no plans right now for starting a weight control plan
_____ I am already following a weight control plan
C. Diet Knowledge and Skills
Please answer all of the following questions about your eating. Place an “X” in the box that best describes you and your behavior.
During the past 3 months, how often did you:
|
1. Use the information about the number of calories in foods to make decisions about what to eat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. Use information about the of carbohydrates in foods to make decisions about what to eat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Use information about the number of grams of fat in foods to make decisions about what to eat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. Deliberately skip a meal or snack to cut calories or fat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. Deliberately take small portion sizes to cut calories, sugar or fat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Use low-calorie, lite, reduced-fat, or fat-free products? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
7. Use sugar free or reduced sugar products? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
8. Resist the temptation to eat a food you want because it is too high in fat, sugar, or calories? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
9. Use a written diet or meal plan to decide what foods to eat? |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
D. Diet Change Readiness
Decision Making & Behavior Related to Diet and Blood Glucose Control
Food can have a big effect on the blood glucose level of a person with diabetes. Please answer the following questions about things you may or may not do to control your blood glucose using food.
1. Are you currently trying to follow a diet plan in order to better control your blood glucose?
_____ Yes, I have a plan I am trying to follow
_____ No, I am not following a plan but I am conscious of how food affects my blood
sugar
_____ No, I really do not pay attention to how food affects my blood sugar
2. If you are following a plan, what kind of plan are you using?
_____ I do not use any kind of diet plan
_____ Carbohydrate counting
_____ The food exchange system
_____ Total available glucose (TAG)
_____ Healthy foods
_____ The food guide pyramid
_____ Fat gram counting
_____ Other
3. If you are NOT currently following a diet or meal plan to better control your blood glucose, is this something you plan to do in the future?
_____ I am already following a diet or meal plan.
_____ Yes, I plan to start within the next month
_____ Yes, I plan to start within the next six months
_____ No, I have no plans right now for starting to follow a diet or meal plan
E. Diet Decision Making
Even if you are not using a diet or meal plan as part of your diabetes care, please answer all of the following questions.
During the past 3 months, how often did you:
|
1. Eat your meals and snacks at the same time each day. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. Choose the portion sizes of foods carefully so that your blood sugar will not be too high or too low. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Use the exchange system to decide what foods or how much of certain foods to eat. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. Use information about the grams of carbohydrates in foods to make decisions about what or how much to eat. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. Use information about the grams of carbohydrates in the foods you are eating to decide how much insulin to take. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Deliberately eat more or less food to adjust for a change in your usual exercise or physical activity. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
F. Eating problems
The next section focuses on behaviors that make it hard for people to lose weight and control blood sugar.
During the past 3 months, how often did you:
1. Overeat? By overeating, we mean eating until you fell stuffed or too full.
_____ never
_____ 1 time a month of less
_____ 2-3 times per month
_____ 1-3 times a week
_____ 4-6 times a week
_____ 1 or more times per day
2. Eat unplanned snacks? That is, how often do you find yourself snacking on foods then thinking “I wish I had not eaten that?”
_____ never
_____ 1 time a month or less
_____ 2-3 times per month
_____ 1-3 times a week
_____ 4-6 times a week
_____ 1 or more times per day
3. Make poor food choices? That is, how often do you find that you have eaten a particular food then thought “I wish I had not eaten that?”
_____ never
_____ 1 time a month or less
_____ 2-3 times per month
_____ 1-3 times a week
_____ 4-6 times a week
_____ 1 or more times per day
G. Diet Barriers
The next set of questions had to do with when and where overeating, unplanned snacking, or poor food choices occur. Each question asks about a particular kind of situation. Think about these behaviors and how much of a problem each situation is for you in trying to control these behaviors.
During the past 3 months, how often have you had a problem with each of the following?
|
1. Eating problems when feeling, stressed, anxious depressed, angry, or bored. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. Eating problems because of hunger or food cravings. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Eating problems because family or friends tempt you or are not very supportive of your efforts to eat right. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. Eating problems when eating away from home (e.g., fast food, restaurants, relatives, pot lucks). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. Eating problems because you feel deprived due to trying to follow a diet. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Eating problems because you feel discouraged due to lack of results (e.g., no weight loss, high blood sugars). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
7. Eating problems because you are to busy with family, work, or other responsibilities. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
H. Medication use
This section focuses on your use of medications to treat diabetes.
1. Has your doctor prescribed pills for your diabetes?
_____ Yes
_____ No
2. How often are you supposed to take these pills?
_____ I do not take pills for my diabetes
_____ Occasionally as needed
_____ Once per day
_____ Twice per day
_____ Three or more times per day
3. How often do you end up taking these pills?
_____ I do not take pills for my diabetes
_____ I never miss a dosage.
_____ I miss a dose a couple times a month or less
_____ I miss a dose once or twice a week
_____ I miss a dose three to five times a week
_____ I miss a dose almost every day
_____ I never take my prescribed pills
4. Has your doctor prescribed insulin shots for your diabetes?
_____ Yes
_____ No
5. How often are you supposed to take insulin?
_____ I don’t take insulin
_____ Occasionally as needed
_____ Once a day
_____ Twice a day
_____ Three or more times a day
6. How often do you end up taking your insulin?
_____ I have not been prescribed insulin for my diabetes
_____ I never miss a shot
_____ I miss a couple times a month
_____ I miss once or twice a week
_____ I miss three to five times a week
_____ I miss almost every day
_____ I never take my prescribed insulin
I. Medication Barriers
The next set of questions has to do with when and where you miss taking your medications (either pills or insulin). Each question asks about a particular kind of situation that might cause you to forget or skip your medicine.
During the past 3 months, how often has each of the following caused a problem in taking your prescribed medicine?
|
1. Feeling stressed, anxious depressed, angry, or bored. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. The medicine has unpleasant side effects. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Family or friends are not very Supportive. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. When away from home (e.g., on vacation, business trips, at restaurants, pot lucks). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. My daily schedule (waking, going to bed, eat, work, etc.) is different from one day to the next.. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Feel discouraged due to lack of results (e.g., no weight loss, high blood sugars). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
7. Being too busy with family, work, or other responsibilities. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
8. The medication is too expensive |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
J. Blood glucose monitoring
The next few questions have to do with testing your blood glucose
1. How often have you been told to test your blood glucose?
_____ I have not been told to test my blood glucose
_____ Occasionally as needed
_____ A couple times a month
_____ 1 or 2 times a week
_____ 3 to 6 times a week
_____ Once a day
_____ Twice a day
_____ 3 or 4 times a day
_____ 5 or more times a day
2. How often do you actually test your blood glucose?
_____ I have not been told to test my blood glucose
_____ Occasionally as needed
_____ A couple times a month
_____ 1 or 2 times a week
_____ 3 to 6 times a week
_____ Once a day
_____ Twice a day
_____ 3 or 4 times a day
_____ 5 or more times a day
K. Blood Glucose Monitoring Barriers
The next set of questions has to do with when and where you forget to test your blood glucose. Each question asks about a particular kind of situation that might cause you to forget or skip a blood glucose test.
During the past 3 months, how often has each of the following caused a problem in testing blood glucose?
|
1. Feeling stressed, anxious depressed, angry, or bored. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. I hate to stick myself. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Family or friends are not very supportive. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. When away from home (e.g., on vacation, business trips, at restaurants, relatives). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. My daily schedule (waking, going to bed, eat, work, etc.) is different from one day to the next.. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Feel discouraged due to lack of results (e.g., no weight loss, high blood sugars). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
7. Being too busy with family, work, or other responsibilities. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
8. The testing supplies are too expensive |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
L. Physical Activity
The next few questions are about your level of physical activity.
1. Has your doctor advised you to get more exercise?
_____ Yes
_____ No
_____ Don’t know
2. How active is your daily routine? How much physical activity do you get as a result of going to work, shopping, housework, yard work, and other daily activities?
_____ Very inactive
_____ Inactive
_____ A little activity
_____ A moderate amount of activity
_____ Active
_____ Very active
3. How often do you set aside time to exercise. How often do you do something physically active like walking, running, cycling, going to the gym or participating in sports?
_____ I never exercise
_____ A couple times a month
_____ 1 or 2 times a week
_____ 3 to 4 times a week
_____ 5 to 6 times a week
_____ Once a day
_____ More than once a day
M. Exercise Barriers
The next set of questions has to do with why you find it hard to start exercising or hard to stick with an exercise plan.
During the past 3 months, how often have you had trouble exercising because of each of the following?
|
1. Feeling stressed, anxious depressed, angry, or bored. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
2. Exercise and physical activity cause pain and discomfort for me. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
3. Family or friends are not very supportive. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
4. When away from home (e.g., on Vacation, business trips, at relatives). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
5. My daily schedule (waking, to bed, eat, work, etc.) is different from one day to the next. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
6. Feel discouraged due to lack of results (e.g., no weight loss, high blood sugars). |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
|
7. Being too busy with family, work, or other responsibilities. |
Never |
1 time per month or less |
2-3 times per month |
1-2 times per week |
4-6 times per week |
1 or more times per day |
