Phase 2 Follow-Up Questionnaire — Health Behavior Change Lab

Enter your ID Number here

Comments

Is this your 6-week OR 3-month follow-up from your first questionnaire?

6-week
3-month

Managing a chronic illness can be time-‐consuming and challenging. It can involve taking medicine daily, exercising, following a specific diet, regular doctor visits, and coping with the impact of the illness upon you and those with whom you interact.

Over the PAST 6 WEEKS, to what extent…

	Not at all	A little	A moderate amount	A large amount	A great deal
1. Has your doctor involved you as an equal partner in making decisions about illness management strategies and goals?
2. Has your doctor or other health care advisor listened carefully to what you had to say about your illness?
3. Has your doctor or other health care provider thoroughly explained the results of tests you had done (e.g. cholesterol, blood pressure, or other laboratory tests)?
4. How important are health care team resources to you in managing your illness?
5. Have family or friends exercised with you?
6. Have you shared healthy low-fat recipes with friends or family members?
7. Family or friends bought or prepared food for you that was especially healthy or recommended?
8. How important is family and friend support in managing your illness?
9. Have you focused on the things you did well to manage your illness instead of those you did not?
10. Have you thought about or reviewed how you were doing in accomplishing your disease management goals?
11. Have you arranged your schedule so that you could more easily do the things you needed to do for your illness?
12. How important are personal resources in managing your illness?
13. Have you walked or exercised outdoors in your neighborhood?
14. Have you walked or done other exercise activities with neighbors?
15. How important are neighborhood resources in managing your illness?
16. Have you eaten at a restaurant that offered a variety of tasty, low-fat food choices?
17. Have you gone to parks for picnics, walks, or other outings?
18. How important is community environment to you in managing your illness?
19. Have you read articles in newspapers or magazine about people who were successfully managing a chronic illness?
20. Have you had health insurance that covered most of the costs of your medical needs including medicine?
21. Have you seen billboards or other advertisements that encouraged not smoking, low-fat eating or regular exercise?
22. How important are media and policy resources in managing your illness?
23. Have you attended free or low-cost meetings (for example Weight Watchers, church groups, hospital programs) that supported you in managing your illness?
24. Have you volunteered your time for local organizations or causes?
25. Have you attended wellness programs or fitness facilities?
26. How important are community and health organizations to you in managing your illness?

The following questions involve your work schedule.

	Not at all	A little	A moderate amount	A large amount	A great deal	Not applicable
27. How important are workplace resources to you in managing your illness?
28. Have you had a flexible work schedule that you could adjust to meet your needs? (Select Not applicable if you don't work.)
29. Has your workplace had rule or policies that made it easier for you to manage your illness (such as no smoking rules or time off work to exercise)? (Select not applicable if not working)
30. Have you had control over your job in terms of making decisions and setting priorities? (Select Not applicable if not working)

Listed below are a number of symptoms that you may or may not have experienced since your diabetes. Please indicate by selecting Yes or No, whether you have experienced any of these symptoms since your diabetes, and whether you believe that these symptoms are related to your diabetes.

Your Views on Diabetes

	Yes	No
I have experienced PAIN symptoms since my diabetes developed
Pain symptoms are related to my diabetes
I have experienced SORE THROAT symptoms since my diabetes developed
Sore throat symptoms are related to my diabetes
I have experienced NAUSEA since my diabetes developed
Nausea is related to my diabetes
I have experienced BREATHLESSNESS since my diabetes developed
Breathlessness is related to my diabetes
I have experienced WEIGHT LOSS since my diabetes developed
Weight loss is related to my diabetes
I have experienced FATIGUE since my diabetes developed
Fatigue is related to my diabetes
I have experienced STIFF JOINTS since my diabetes developed
Stiff joints are related to my diabetes
I have experienced SORE EYES since my diabetes developed
Sore eyes are related to my diabetes
I have experienced WHEEZINESS since my diabetes developed
Wheeziness is related to my diabetes
I have experienced HEADACHES since my diabetes developed
Headaches are related to my diabetes
I have experienced UPSET STOMACH since my diabetes developed
Upset stomach is related to my diabetes
I have experienced SLEEP DIFFICULTIES since my diabetes developed
Sleep difficulties are related to my diabetes
I have experienced DIZZINESS since my diabetes developed
Dizziness is related to my diabetes
I have experienced LOSS OF STRENGTH since my diabetes developed
Loss of strength is related to my diabetes

Please indicate how much you agree or disagree with the following statements about our diabetes by checking the appropriate box.

Your Views on Diabetes

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
My diabetes will last a short time
My diabetes is likely to be permanent rather than temporary
My diabetes will last for a long time
This diabetes will pass quickly
I expect to have this diabetes for the rest of my life
My diabetes is a serious condition
My diabetes has major consequences on my life
My diabetes does not have much effect on my life
My diabetes strongly affect the way others see me
My diabetes has serious financial consequences
My diabetes causes difficulties for those who are close to me
There is a lot which I can do to control my symptoms
What I do can determine whether my diabetes gets worse
The course of my diabetes depends on me
Nothing I do will affect my diabetes
I have the power to influence my diabetes
My actions will have no affect on the outcome of my diabetes
My diabetes will improve in time
There is very little that can be done to improve my diabetes
My treatment will be effective in curing my diabetes
The negative effects of my diabetes can be prevented (avoided) by my treatment
My treatment can control my diabetes
There is nothing which can help my condition
The symptoms of my condition are puzzling to me
My diabetes is a mystery to me
I don’t understand my diabetes
My diabetes doesn’t make any sense to me
I have a clear picture or understanding of my condition
The symptoms of my diabetes change a great deal from day to day
My symptoms come and go in cycles
My diabetes is very unpredictable
I go through cycles in which my diabetes gets better and worse
I get depressed when I think about my diabetes
When I think about my diabetes I get upset
My diabetes makes me feel angry
My diabetes does not worry me
Having this diabetes makes me feel anxious
My diabetes makes me feel afraid

We are interested in what you consider may have been the cause of your diabetes. As people are very different, there is no correct answer for this question. We are most interested in your own views about the factors that caused your diabetes rather than what others including doctors or family may have suggested to you. Below is a list of possible causes for your diabetes. Please indicate how much you agree or disagree that they were causes for you by ticking the appropriate box.

Possible Causes for Your Diabetes

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
Stress or Worry
Hereditary - it runs in my family
A germ or virus
Diet or eating habits
Chance or bad luck
Poor medical care in my past
Pollution in the environment
My own behavior
My mental attitude e.g. thinking about life negatively
Family problems or worries
Overwork
My emotional state e.g. feeling down, lonely, anxious, empty
Aging
Alcohol
Smoking
Accident or injury
My diabetes is a mystery to me
My personality
Altered immunity

In the boxes below, please list in rank-order (1st, 2nd, 3rd) the most important factors you believe caused YOUR diabetes. You may use any of the items from the box above, or you may have additional ideas of your own. FACTOR 1:

FACTOR 2

FACTOR 3

Blood Sugar Testing

	0 - Not at all	1	2	3	4 - Extremely
To what extent are you using your blood sugar testing to decide what to do, like what to eat or how to be physically active, to manage your diabetes?

7-Day Recall

	0	1	2	3	4	5	6	7
On how many days of the last SEVEN DAYS did you test your blood sugar?
On how many of the last SEVEN DAYS did you test your blood sugar the number of times recommended by your health care provider?
On how many of the last SEVEN DAYS did you take your recommended diabetes medications?
On how many of the last SEVEN DAYS did you take your recommended number of diabetes pills?
On how many of the last SEVEN DAYS have you followed a healthful eating plan?
On how many of the last SEVEN DAYS did you eat five or more servings of fruits and vegetables?
On how many of the last SEVEN DAYS did you eat high fat foods such as red meat or full-fat dairy products?
On how many of the last SEVEN DAYS did you space carbohydrates evenly through the day?
On how many of the last SEVEN DAYS did you participate in at least 30 minutes of physical activities?
On how many of the last SEVEN DAYS did you participate in a specific exercise session (such as swimming, walking, biking) other than what you do around the house or as part of your work?

Smoking

	No	Yes
Have you smoked a cigarette (even one puff) during the past SEVEN DAYS?

If yes, how many cigarettes did you smoke on an average day? (Average # of cigarettes/day)

How many city blocks or their equivalent do you normally walk each day? (Let 12 blocks = 1 mile)

What is your usual pace of walking?

How many flights of stairs do you climb UP each day? (Let 1 flight = 10 steps)

List any sports or recreation you have actively participated in during the past year, along with the number of times you participated, the average number of minutes you participated, and how long you've been involved with that physical activity.

characters remaining

Which of these statements best expresses your view?

At least once a week, do you engage in regular activity akin to brisk walking,jogging, bicycling, swimming, etc., long enough to work up a sweat, get your heart thumping, or get out of breath?

Yes
No

If you selected 'Yes' in the previous question, detail what activity you performed and how many times per week you generally perform it. If you selected 'No,' explain why not.

characters remaining

When you are exercising in your usual fashion, how would you rate your level of exertion (degree of effort)?

On a usual WEEK DAY, how many HOURS PER DAY do you spend in the following activities?

Vigorous activity (digging in the garden, strenuous sports, jogging, aerobic dancing, sustained swimming, brisk walking, heavy carpentry, bicycling on hills, etc.)

Moderate activity (housework, light sports, regular walking, golf, yard work, lawn mowing, painting, repairing, light carpentry, ballroom dancing, bicycling on level ground, etc.)

Light activity (office work, driving a car, strolling, personal care standing with little motion, etc.)

Sitting activity (eating, reading, desk work, watching TV, listening to radio, etc.)

Sleeping or reclining

NOTE: YOUR TOTAL HOURS ACROSS THE PREVIOUS QUESTION SHOULD SUM TO 24.

On a usual WEEK END DAY, how many HOURS PER DAY do you spend in the following activities?

Vigorous activity (digging in the garden, strenuous sports, jogging, aerobic dancing, sustained swimming, brisk walking, heavy carpentry, bicycling on hills, etc.)

Moderate activity (housework, light sports, regular walking, golf, yard work, lawn mowing, painting, repairing, light carpentry, ballroom dancing, bicycling on level ground, etc.)

Light activity (office work, driving car, strolling, personal care, standing with little motion, etc.)

Sitting activity (eating, reading, desk work, watching TV, listening to radio, etc.)

Sleeping and reclining

NOTE: YOUR TOTAL HOURS ACROSS THE PREVIOUS QUESTION SHOULD SUM TO 24.

1. 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 have agreed on?

Yes
No
Not sure

Blood Sugar

	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
Sometimes when you test your blood sugar, it can be too high. How often is that a problem for you?
Sometimes blood sugar can be too low causing hypoglycemia (an insulin reaction). How often is this a problem for you?

Are you currently trying to lose weight?

Yes
No

If you are NOT currently trying to lose weight or avoid gaining weight, is this something you plan to do in the future?

Food can have a big effect on the blood glucose level of a person with diabetes. Please answer the following questions about the things you may or may not do to control your blood glucose using food.

Are you currently trying to follow a diet plan in order to better control you 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.

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

If you selected 'Other' in the previous question, please explain:

characters remaining

If you are NOT currently following a diet plan or meal plan to better control your blood glucose, is this something you plan to do in the future?

The next few questions are about your level of physical activity.

Has your doctor advised you to get more exercise?

Yes
No
I don't know

How active is your daily routine? How much physical activity do you get as a result of going to work, shopping, yard work, and other daily activities?

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?

The next set of questions has to do with when and where overeating, unplanned snacks and 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 6 WEEKS, how often have you had a problem with each of the following?

	Never	One time per month or less	Two to three times per month	One to two times per week	Four to six times per week	One or more times per day
1. Eating problems when feeling stressed, anxious, depressed, angry, or bored
2. Eating problems because of hunger or food cravings
3. Eating problems because family or friends tempt you or are not very supportive of your efforts to eat right
4. Eating problems when eating away from home (fast food, restaurants, pot lucks)
5. Eating problems because you feel deprived due to trying to follow a diet
6. Eating problems because you feel discouraged due to lack of results (e.g. no weight loss, high blood sugars)
7. Eating problems because you are too busy with family, work, or other responsibilities

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 6 WEEKS, how often as each of the following caused a problem in TESTING BLOOD GLUCOSE?

	Never	One time per month or less	Two to three times per month	One to two times per week	Four to six times per week	One or more times per day
1. Feeling stressed, anxious, depressed, angry or bored
2. I hate to stick myself
3. Family or friends are not very supportive
4. When away from home (e.g. on vacation, business trips, at relatives)
5. My daily schedule (waking, go to bed, eat, work, etc.) is different from one day to the next
6. Feel discouraged due to lack of results (e.g. no weight loss, high blood sugars)
7. Being too busy with family, work, or other responsibilities
8. The testing supplies are too expensive

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 6 WEEKS, how often have you had trouble exercising because of each of the following?

	Never	One time per month or less	Two to three times per month	One to two times per week	Four to six times per week	One or more times per day
1. Feeling stressed, anxious, depressed, angry, or bored
2. Exercise and physical activity cause pain and discomfort for me
3. Family or friends are not very supportive
4. When away from home (e.g. on vacation, business trips, at relatives)
5. My daily schedule (waking, go to bed, eat, work, etc.) is different from one day to the next
6. Feel discouraged due to lack of results (e.g. no weight loss, high blood sugars)
7. Being too busy with family, work, or other responsibilities

For each of the following questions, please choose the number that corresponds to your confidence that you can do the tasks regularly.

	1 - Not at all Confident	2 - Somewhat	3 - Moderately	4 - Very	5 - Extremely Confident
1. How confident do you feel that you can eat your meals every 4 to 5 hours every day, including 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?
3. How confident do you feel that you can choose the appropriate foods to eat when you are hungry (for example, snacks)?
4. How confident do you feel that you can exercise 15 to 30 minutes, 4 to 5 times a week?
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 to do when your blood sugar level goes higher or 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?

How many family members and close friends can you count on for help and encouragement with healthy foods?

Which of the following diabetes issues are currently a problem for you?

	Strongly disagree	Disagree	Neither agree nor disagree	Agree	Strongly agree
1. Worrying about the future and the possibility of serious complications.
2. Feeling guilty or anxious when you get off track with your diabetes management.
3. Feeling scared when you think about living with diabetes.
4. Feeling discouraged about your diabetes regimen.
5. Worrying about low blood sugar reactions.
6. Feeling constantly burned-out by the constant effort to manage diabetes.
7. Not knowing if the mood or feelings you are experiencing are related to your blood glucose level.
8. Coping with the complications of diabetes.
9. Feeling that diabetes is taking up too much mental and physical energy.
10. Feeling constantly concerned about food.
11. Feeling depressed when you think about living with diabetes.
12. Feeling angry when you think about living with diabetes.
13. Feeling overwhelmed by your diabetes regimen.
14. Feeling alone with diabetes.
15. Feelings of deprivation regarding food and meals.
16. Not having clear and concrete goals for your diabetes care.
17. Uncomfortable interactions around diabetes with family/friends.
18. Not accepting diabetes.
19. Feeling that friends/family are not supportive of diabetes management efforts
20. Feeling unsatisfied with your diabetes physician.

This survey asks for your views about your health. This information will help you keep track of how you feel and how well you are able to do your usual activities. Answer every question by selecting the answer as indicated. If you are unsure about how to answer a question, please give the best answer you can.

In general, would you say your health is:

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

	Yes, limited a lot	Yes, limited a little	No, not limited at all
a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
b. Climbing several flights of stairs

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

	Yes	No
a. Accomplished less than you would like
b. Were limited in the kind of work or other activities

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

	Yes	No
Accomplished less than you would like
Did work or other activities less carefully than usual

During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

These questions are about how you feel and how things have been with you DURING THE PAST FOUR WEEKS. For each question, please give the one answer that comes closest to the way you have been feeling.

	All of the time	Most of the time	Some of the time	A little of the time	None
Have you felt calm and peaceful?
Did you have a lot of energy?
Have you felt downhearted and blue?

During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting friends, relatives, etc.)?