Power to Prevent - National Diabetes Education Program - National ...
Power to Prevent - National Diabetes Education Program - National ...
Power to Prevent - National Diabetes Education Program - National ...
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Where Am I Right Now?<br />
Thinking about your physical activity and eating over the past three months, please answer the<br />
following questions.<br />
Please circle one number <strong>to</strong> indicate how strongly you agree or disagree with the following<br />
statements. (Check “Don’t know or refused” if you do not know or do not want <strong>to</strong> answer.)<br />
Right now: Strongly<br />
agree<br />
Agree<br />
Not<br />
sure<br />
Disagree<br />
Strongly<br />
disagree<br />
1. I eat healthily. 5 4 3 2 1<br />
2. I get enough physical activity. 5 4 3 2 1<br />
3. I want <strong>to</strong> eat more healthily. 5 4 3 2 1<br />
4. I want <strong>to</strong> be more physically active 5 4 3 2 1<br />
Physical Activity<br />
Please answer the following questions about your level of physical activity.<br />
Don’t know or<br />
refused<br />
During the past week, what was the highest level of physical activity you got? (Check the best<br />
answer below.)<br />
No specifc physical activity routine (just activities of daily living such as walking in the<br />
house or at work)<br />
Light intensity physical activity (for example, slowly walking the dog, breathing and heart<br />
beat are not faster)<br />
Moderate intensity physical activity (brisk walking, light yard work e.g. raking leaves or<br />
mowing lawn, biking at a casual pace)<br />
Vigorous physical activity (jogging/running, swimming laps, playing basketball or soccer)<br />
During the last week, how many days were you physically active at the level you checked above for<br />
at least 30 minutes per day?<br />
None 3 <strong>to</strong> 5 days<br />
<strong>to</strong> 2 days 6 <strong>to</strong> 7 days<br />
Eating<br />
Please answer the following question about your eating.<br />
How do you usually decide what <strong>to</strong> eat? (Please check all that apply.)<br />
Count calories<br />
Count carbohydrates<br />
Avoid sweets and sugars<br />
Limit amount of fat<br />
Eat anything I want or whatever is convenient<br />
Other: _______________________________________________________________________<br />
NDEP <strong>Power</strong> <strong>to</strong> <strong>Prevent</strong> Appendices 38