Power to Prevent - National Diabetes Education Program - National ...

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Pre-Session 1 Questionnaire (Fill Out This Questionnaire at the Beginning of Session 1) Name or other identifer (such as initials with day and month of birth): ______________________ Welcome to our program! You are asked to fll out this questionnaire so that you will be able to see the amount change in your attitudes, lifestyles, and behaviors from the time you start this program (right now) to the time you fnish the program. You will compare your answers on this questionnaire with a similar questionnaire you will complete at the end of the program to see how well you are achieving your goals. If you do not want to write your name on this questionnaire, use another identifer, such as the frst letters of your frst and last names and your day and month of birth (for example, MR 2/ 7), so that the program leader can return the questionnaire to you at the end of the program. Please use the same identifer for every questionnaire you complete during the program so that all of your questionnaires can be returned to you. Be Honest in Your Answers. This is for You! Goals and Expectations My goals are to: (Please check all that apply, or write in your own.) Lose weight Feel better about myself Be more physically active Learn to eat and/or cook more healthily Learn more about how to control diabetes in general Take control over my diabetes Prevent diabetes in myself and/or my family Other:_________________________________________________________________________ My expectations are that I will: (Please check all that apply, or write in your own.) Learn more about diabetes control Learn more about diabetes prevention Gain support from other members of the group Be able to teach my family about diabetes prevention Be able to make changes in my eating Be able to make changes in my physical activity Other:_________________________________________________________________________ NDEP Power to Prevent Appendices 37
Where Am I Right Now? Thinking about your physical activity and eating over the past three months, please answer the following questions. Please circle one number to indicate how strongly you agree or disagree with the following statements. (Check “Don’t know or refused” if you do not know or do not want to answer.) Right now: Strongly agree Agree Not sure Disagree Strongly disagree 1. I eat healthily. 5 4 3 2 1 2. I get enough physical activity. 5 4 3 2 1 3. I want to eat more healthily. 5 4 3 2 1 4. I want to be more physically active 5 4 3 2 1 Physical Activity Please answer the following questions about your level of physical activity. Don’t know or refused During the past week, what was the highest level of physical activity you got? (Check the best answer below.) No specifc physical activity routine (just activities of daily living such as walking in the house or at work) Light intensity physical activity (for example, slowly walking the dog, breathing and heart beat are not faster) Moderate intensity physical activity (brisk walking, light yard work e.g. raking leaves or mowing lawn, biking at a casual pace) Vigorous physical activity (jogging/running, swimming laps, playing basketball or soccer) During the last week, how many days were you physically active at the level you checked above for at least 30 minutes per day? None 3 to 5 days to 2 days 6 to 7 days Eating Please answer the following question about your eating. How do you usually decide what to eat? (Please check all that apply.) Count calories Count carbohydrates Avoid sweets and sugars Limit amount of fat Eat anything I want or whatever is convenient Other: _______________________________________________________________________ NDEP Power to Prevent Appendices 38
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Power to Prevent A Family Lifestyle
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Credits and Acknowledgments NDEP Af
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Table of Contents Foreword. . . . .
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Appendix Materials and Resources Th
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Additional Resources for Program Le
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Organizations Black Women’s Healt
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in the Forward/Introduction section
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NDEP GAME PLAN Food and Activity Tr
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Session No. and Title Session 10 Pa
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Session Duration Each session is de
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Session Preparation As program lead
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Refreshments and healthful snacks,
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Conducting the Session NOTE: Times
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Say: “Let’s fll in our Individu
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The program leader ends the session
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NOTE: You could choose other sticke
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NDEP Power to Prevent Program Leade
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Getting Started Getting started wit
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NDEP Power to Prevent Program Leade
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Key to Icons Used in Power To Preve
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At least two helpers to assist peop
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Say: “The objectives for today’
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What are some of the Complications
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Pledge Possible Improvements I’ll
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NDEP Power to Prevent Session 0
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Purchase stickers (stars, smiling f
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Discussion Points Say: “Small Ste
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Preparation and Reminders for the N
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Advance Preparation NOTE: The NDEP
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Discussion Points Say: “Healthy e
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Activity Take a 5- to 0-minute brea
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Tips for Inviting a Registered Diet
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NDEP Power to Prevent Session 3 0
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Appendix U: Why Physical Activity I
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in silence. Suggest that if partici
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Ask participants to name ways that
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Optional Activities 4.1 Visit an At
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also be downloaded from the NDEP We
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Say: “Cooking can be a fun activi
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Brochure 7 Principles for Controlli
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Conducting the Session Welcome Welc
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List answers on a fipchart, and mak
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Conducting the Session Welcome Welc
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Activity Take a 5- to 0-minute brea
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Advance Preparation In addition to
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Further Information on Diabetes Pre
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Obtain copies of Appendix Q: Energi
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Review of Discussion Points Say:
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Advance Preparation In addition to
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My Pyramid Some people in your grou
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Bring copies of menus from several
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Example of better “I statement”
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If you plan do to the Optional Acti
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It is recommended that people with
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Page 129 and 130: Advance Preparation for Session 12
Page 131 and 132: Make photocopies of the Post-progra
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Page 137 and 138: NDEP Power to Prevent Appendices 2
Page 139 and 140: Sample Letter to Potential Partners
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Page 151 and 152: Community newspaper organizations S
Page 153 and 154: Selecting and Securing a Regular Me
Page 155 and 156: Reward participants for fnishing th
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Page 161 and 162: “I can accept failure. Everyone f
Page 171: Session Questionnaire Intent 1 Pre-
Page 175 and 176: The next questionnaire is an option
Page 177 and 178: Feelings About Having Diabetes Plea
Page 179 and 180: Pre-Session 3 Questionnaire (Fill o
Page 181 and 182: Post-Session 3 Questionnaire (Fill
Page 183 and 184: Pre-Session 4 Questionnaire (Fill o
Page 187 and 188: Please answer the following. (Check
Page 189 and 190: Check Ups Please check “Yes” or
Page 191 and 192: How confdent are you now? Please ci
Page 195 and 196: Where Am I Right Now? Thinking abou
Page 199 and 200: 1 Start Here 2 Check Calories 3 Lim
Page 213 and 214: The Plate Method The Plate Method c
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Spotting Denial Denial has a few ca
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If you have three or more of these
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Let Anger Be Your Ally The goal is
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Learning to Relax There are many wa
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NDEP Power to Prevent Appendices 96
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Si Usted Tiene Diabetes, ¡Sepa los
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Small Steps. Big Rewards. Prevent T
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Publications and Resources for Chil
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Team Care: Comprehensive Lifetime M
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Team Care: Comprehensive Lifetime M
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New Beginnings: A Discussion Guide
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