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

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Pre-Program Questionnaire for People with Diabetes (Optional Pre-Session 1 Questionnaire) Name or other identifer (such as initials with day and month of birth): ______________________ This questionnaire is for those of you whom a doctor has told that you have diabetes (“sugar”). What changes, if any, would you like to make now? Please circle one number to indicate how confdent you are that you can do the following things. (Check “Don’t know or refused” if you do not know or do not want to answer.) Problem Solving for Blood Sugar Levels Sure I can Think I can Not sure I can Don’t think I can 1. Prevent high blood sugar levels 4 3 2 1 2. Treat high blood sugar levels 4 3 2 1 3. Prevent low blood sugar levels 4 3 2 1 Reducing Risks for Diabetes Complications 4. Get diabetes check-ups for mouth, feet, and eyes Sure I can Think I can Not sure I can Don’t think I can 4 3 2 1 5. Check my feet 4 3 2 1 Living with Diabetes Sure I can think I can Not sure I can Don’t think I can 6. Cope with diabetes 4 3 2 1 7. Get support from my medical team 4 3 2 1 Don’t know or refused Don’t know or refused Don’t know or refused NDEP Power to Prevent Appendices 4
Feelings About Having Diabetes Please tell us how you feel about your diabetes. Please circle only one number for each question. (Check “Don’t know or refused” if you do not know or do not want to answer.) 1. How sure are you that you can manage your diabetes? 2. How much do you feel your family/friends support your efforts for diabetes control? 3. How much does diabetes interfere with your job, school, or daily activities? 4. How much does diabetes reduce your well-being? 5. How much does your diabetes seem out of control? 6. How much do you fear you will develop complications? 7. How often do you feel overwhelmed by your diabetes? 8. How often do you feel depressed about your diabetes? A lot Some A little Not at all 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 4 3 2 1 Don’t know or refused Please put your name (or your initials with day and month of birth) on this questionnaire and give it to your program leader. NDEP Power to Prevent Appendices 42
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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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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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Optional Activities 1.1 Review the
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Page 125 and 126: Discussion Points Say: “Making ch
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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
Page 147 and 148: Black Women’s Health Imperative w
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 and 172: Session Questionnaire Intent 1 Pre-
Page 173 and 174: Where Am I Right Now? Thinking abou
Page 175: The next questionnaire is an option
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
Page 223 and 224: Spotting Denial Denial has a few ca
Page 225 and 226: 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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